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TOP OFFICIALS (TOPOFF) 
EXERCISE SERIES 

TOPOFF 2 (T2) 

After Action Report 

September 30, 2003 





Homeland 

Security 





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ADMINISTRATIVE HANDLING INSTRUCTIONS 


4. 

5. 


The title of this document is Top Officials (TOPOFF) Exercise Series: TOPOFF 2 (T2) 
After Action Summary Report. 

Information contained in this document is intended for the exclusive use of T2 Exercise 
Series participants. Material may not be reproduced, copied, or furnished to non-cxercise 
personnel without written approval from the Exercise Directors. 

This document should be safeguarded, handled, transmitted, and stored in accordance 
with appropriate Canadian, U.S. Department of Homeland Security (DHS), U.S. 
Department of State (DOS), the State of Illinois, the State of Washington, and local/city 
security directives. This document is marked For Official Use Only tF QUOh and 
information contained herein ha.s not been given a security clas&ificatioi) pursuant to the 
criteria of an Executive Order, but this document ^ to be wrfbheld from the public 
because disclosure would cause a foreseeable hiym 10, an Interest protected by one or 
more FOUO exemptions. 

Reproduction of this document, in whole Of in part, withewt prior approval of DHS is 
prohibited. 

DHS, Office for Domestic Preparedness (ODP), and DOS, the Office of the Coordinator 
for Counterterrorism, cosponsored the T2 Exercise Series. Mr. Theodore Mackliii 


( 0 ( 6 ) 


and 


and Mr . Corey Gruber ( 202-514-0284) are the ODP Points of Contact (POC) 

]. the Office of the Coordinator for Counterten orism, is 


(bK6) 


the POC for international play. 

This report is intended for the use of Federal. State, and local (FSL) officials responsible 
for homeland security, it is intended to improve the FSL plans to prevent and respond to 
weapons of mass destruction by understanding the lessons learned from T2. 


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Top Officials (TOPOFF) 
Exercise Series: 

TOPOFF 2 (T2]^ 
After Action Summary Report 

V— 

^^epared^for 

U.S. Departin5?twf,Honieland Security 
Office for Domestic Preparedness 
by AMTI and the CNA Corporation 
Under Schedule Number GS-10F-0324M, 
Order Number 2003F028 





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SUMMARY REPORT 


1. Introduction 


Top Officials (TOPOFF) 2 (T2) was a Congressionally-mandated, national combating terrorism 
exercise. The exercise was designed to improve the nation’s domestic incident management 
capability by exercising the plans, policies, procedures, systems, and facilities of Federal, State, 
and local (FSL) response organizations against a series of integrated and geographically 
dispersed terrorist threats and acts. 

T2 was cosponsored by the U.S. Department of Homeland Security (DHS) and the U.S. 
Department of State. The T2 After Action Report (AAR) provides the findings from the analysis 
of the Full-Scale Exercise (FSE), and also integrates the findings from the pre-FSE seminars and 
the Large-Scale Game (LSG). 

The domestic objectives of the T2 exercise were to improve the nation’s capacity to manage 
compiex/extreme events; create broader operating frameworks of expert domestic incident 
management and other systems; validate FSL authOTities, strategies, plans, policies, procedures, 
protocols, and synchronized capabilities; and build a sustainable, systematic exercise process for 
advancing domestic preparedness. There was also an international aspect of T2 that exercised a 
segment of the Canadian response to weapons of mass destruction (WMD) attacks upon the 
United States. This cross-border play focused on bilateral goals in the areas of communication, 
preparedness, and response to WMD terrorism incidents. 

T2 was the largest and most comprehensive terrorism response exercise ever conducted within 
the United States. The T2 exercise scenario depicted a fictitious, foreign terrorist organization 
that detonated a simulat^^radiological dispersal device (RDD) in Seattle, Washington, and 
released the Pneumonic Plague (Yersinia pestis) in several Chicago area locations. There was 
also significant pre-exercise intelligence play, a cyber attack, and credible terrorism threats 
against other locations. \ 



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II. Background 


A. T2 Authorization 

Public Law 106-553 authorized T2, and Senate Report 106-404 outlined the concept. T2 
supported the National Security Council’s Policy Coordinating Committee on Counter-terrorism 
and National Preparedness Exercise Sub-group requirement for a large-scale, counterterrorism 
exercise commencing in 2002 and finishing in 2003. While T2 planning began under earlier 
Presidential Directives, the Homeland Security Presidential Directive (HSPD)-5 articulates the 
new federal incident management policy that ultimately guided the exercise. Participating FSL 
authorities were asked to submit exercise objectives to T2 planners at the start of the T2 design 
cycle to ensure that the exercise design would support participant objectives while also 
addressing national priorities. 

B. Exercise Design and Concept 

The first TOPOFF Exercise (TOPOFF2000) was a single, no-notice, FSE co-chaired by the 
Department of Justice and the Federal Emergency Management Agency (FEMA) in May 2000, 
Unlike TOPOFF2000, T2 was designed as an “open” exercise in which participants were 
introduced to the exercise scenario prior to the FSE through a cycle of exercise activity of 
increasing complexity that included: 

• A series of seminars that explored emergency public information, RDD response, 
bioteiTorism, and national direction and control issues; 

• An LSG that explored intermediate and long-term recovery issues; 

• An Advanced Distance Learning Exercise, conducted in conjunction with the National 
Direction and Control Seminar, that employed distance education technology to 
disseminate information and provide interactive training opportunities; and 

• The Top Ojficials Seminar that brought together top government officials from 25 FSL 
agencies and departments, and the Canadian Government, in a round-table discussion to 
explore intergovernmental domestic incident management in response to WMD terrorist 
attacks upon the United Stales. 

These activities culminated in an FSE which was played out from May 12 to May 16, 2003. 

The purpose of the open exercise design was to enhance the learning and preparedness value of 
the exercise through a “building-block” approach, and to enable participants to develop and 
strengthen relationships in the national response community. Participants at all levels stated that 
this approach has been of enormous value to their domestic preparedness strategies. 


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III. Findings of the Exercise Analysis 


A. Special Topics 

The FSE exercised numerous critical aspects of the national response to radiological and 
bioterrorism attacks. This response cut across several predetermined areas of analysis, as 
decided by T2 participants in earlier exercise activities (see below). Specific special interest 
items included the following: 

• Alerts and Alerting: The Elevation of the Homeland Security Advisory System Threat 
Level to Red; 

• Declarations and Proclamations of Disaster and Emergency; 

• Department of Homeland Security Play in T2: The Role of the Principal Federal Official: 

• Data Collection and Coordination: Radiological Dispersal Device Plume Modeling and 
Deposition Assessment in Washington; 

• Play Involving the Strategic National Stockpile; 

• Hospital Play in the Illinois Venue: Resources. Communications, and Information 
Sharing during a Public Health Emergency; 

• Decision-Making Under Conditions of Uncertainty: The Plague Outbreak in the Illinois 
Venue; and 

• Balancing the Safety of First Responders and the Rescue of Victims. 

B. Core Areas of Analysis 

Rather than evaluating participant ability and performance or specific agency-by-agency 
objectives, the exercise evaluation methodology focused on the objective analysis of decision 
and coordination processes that .support the nation’s top officials and the broader system of FSL 
agencies. The exercise events were analyzed as they unfolded in light of six major areas of 
analysis, identified through a survey of TOPOFF 2000 findings, and other exercise or real-world 
lessons learned: 

• Emergency Decision-Making and Public Policy; 

• Emergency Public Information; 

• Communications. Coordination, and Connectivity; 

• Jurisdiction: 

• Resource Allocation; and 

• Anticipating the Enemy. 


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IV. Artificialities 


Artificialities are inherent in every exercise and result from the simulated nature of exercises. 
False conclusions can arise if the natures and effects of artificialities are not accounted for during 
the analysis process. Some artificialities were essential in exercise design including the 
simulated RDD explosion, prescheduled top official play, limited public involvement, and 
notional road closures. Some artificialities were specific to the T2 design process, such as the 
known scenario and the lack of 24-hour play by some entities. Other T2 artificialities, while not 
preplanned, were nonetheless anticipated in the exercise, as it encouraged free play. The 
evaluation team researched, documented, and factored all such artificialities iflto the ana^>;sis of 
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V. Special Topics 


A. Alerts and Alerting: The Elevation of the Homeland Security Advisory System Threat 
Level to Red 

The FSE exercised the use of the Homeland Security Advisory System (HSAS); the decision to 
elevate the HSAS Threat Level to Red; and the actions associated with Threat Level “Severe,” or 
Red. It also allowed examination of the implications of rai.sing specific regions or localities to 
Red. The FSE highlighted that further refinement of this advisory system is needed. 

Significant findings from the FSE include the following: 

• Following the local threat level elevations of Seattle and King County early in the FSE, 
there was uncertainty as to the status of the HSAS Threat Condition of other jurisdictions, 
This situation was caused in part by a) a lack of awareness of local threat advisory 
systems; b) inconsistent or nonexistent formal notification protocols of threat elevations; 
and c) a lack of language clarity— elevations of the HSAS are referred to as elevations of 
the “National Threat Level,” even if applied to regions or localitiw; 

• The FSL response to elevations of the HSAS ne«ils to be further developed and 
synchronized. Participants in the T2 After Action Conference (AAC) suggested the 
development of a tiered, operational response linked to the HSAS levels and based upon 
the nature of the threat. This system would be defined by a coalition of FSL agencies and 
would offer a comprehensive operaticmal response framework that jurisdictions at all 
levels could use to help define their response plans at each HSAS Threat Condition. DHS 
is leading an interagency effort to review these recommendations and make appropriate 
refinements to the HSAS; State, local, and private sector constituents are active partners 
in this process; and 

• Agencies are concerned about the lack of specific intelligence accompanying threat level 
elevations and the cost of maintaining a raised threat level. DHS is currently examining 
ways to improve information flow to and from State and local governments and the 
private sector regarding changes in alert level. Also, the DHS-led HSAS Working Group 
is currently addressing the economic and operational impacts of a raised threat condition. 

B. Declarations and Proclamations of Disaster and Emergency 

During the FSE, several declarations and proclamations of emergencies and disasters were 
issued. Local and State jurisdictions in both exercise venues invoked their authorities to declare 
emergencies and requested Federal assistance under the Stafford Act. These requests ultimately 
led to a Presidential Declaration of Major Disaster in Washington and a Presidential Declaration 
of Emergency in Illinois. The bioterrorism attack in Illinois was especially challenging as its 
impact involved multiple counties, the city of Chicago, and the state of Illinois. In addition, the 
Secretary of the Department of Health and Human Services (HHS) declared a Public Health 
Emergency in the state of Illinois under the authorities of the Public Health Service Act. This 
occurred before the Presidential Declaration of Emergency, enabling the activation of several 
response assets. 

Significant findings from the FSE include the following: 


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• Officials in Illinois requested a Major Disaster Declaration to obtain maximum Federal 
assistance for the growing bioterrorism disaster, out of concern for the perceived five 
million dollar limit and other limits to Federal assistance in declarations of emergency. 
Some were unaware that the President can approve an expenditure of funds in excess of 
that limit under the conditions where, as stated in the Stafford Act, “continued emergency 
assistance is immediately required; there is a continuing and immediate risk to lives, 
property, public health, or safety; and necessary assistance will not otherwise be provided 
on a timely basis.” In addition, the nature of the declaration in Illinois led to concerns 
about whether some individual assistance programs, which are specifically authorized for 
a disaster but not for an emergency, would be authorized; 

• It is worth noting that during the FSE, the President did not declare the large-scale 
bioterrorism attack a Major Disaster under the Stafford Act. It is not clear from the FSE 
whether the difference in declaring an emergency or a major disaster would result in 
substantive operational issues given the exception clauses under declarations of 
emergency as previously de.scribed; 

• There was some uncertainty regarding the relationships between State and local 
declarations of emergency. In Illinois there was some uncertainty as to whether county- 
level declarations needed to be enacted in light of a State declaration of emergency or 
whether a state declaration made these moot. Officials determined that in legal terms, 
county-level declarations needed to be enacted, even when preceded by a State 
declaration of emergency, to access funds that the State declaration made available; and 

• The relationships between the authorities and resources brought to bear under the Public 
Health Act and the Stafford Act should continue to be exercised. Additional clarity 
regarding the authorities and resources brought to bear under both Acts is required. 

C. Department of Homeland Security Play in T2: The Role of the Principal Federal 
Official 

The FSE was the first major opportunity for the newly created DHS to exercise and experiment 
with its domestic incident management organization, functions, and assets. For example, the 
DHS Principal Federal Official (PFO) concept was first implemented during the FSE, which 
provided the opportunity to examine the role of the PFO during an emergency response. During 
the FSE. the PFOs in both venues facilitated integrated communications and coordinated action 
planning. In addition, they both encouraged active communications with state and local 
authorities. 

Significant findings from the FSE include the following: 

• The PFO was well-received and successfully integrated into the unified command 
structure in both venues. In Seattle, the PFO quickly instituted a unified command to 
manage the overall Federal response and coordinate integrated communications and 
action planning. The PFO in Seattle also helped to prioritize and adjudicate between the 
often-competing needs of the crisis and consequence management sides of the response 
phase. In Illinois, the PFO worked within the framework of a unified command to ensure 
that integrated communications were achieved and that action plans were coordinated; 


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• The PFO relationships with Federal officials differed in part due to the different problems 
that each encountered with the two different attacks. In Seattle, although an RDD was 
involved, the event unfolded in more of a traditional first-responder fashion with a 
relatively well-delineated disaster site. In Illinois, events unfolded more gradually, as 
would be expected in a disease outbreak. As a result, the PFOs in each venue had 
different relationships with the FEMA Regional Director (RD), the FEMA Federal 
Coordinating Officer (FCO), and the FBI Special-Agent-ln-Charge (SAC). The roles and 
responsibilities of the PFO relative to FEMA and FBI officials have been clarified 
through issuance of the Initial National Response Plan (INRP); and 

• Both PFOs required additional technical support beyond their deployed administrative 
and security details. The FSE highlighted the need for the PFO to have a dedicated staff 
with the flexibility and expertise to support all emergencies, natural and terrorist-related. 
DHS has recently developed operational procedures for providing additional resources to 
the PFO to facilitate domestic incident management activities. Further delineation of the 
roles and responsibilities of the PFO, as well as PFO support requirements, will be 
included in the final version of the National Response Plan (NRP). 

D. Data Collection and Coordination: Radiological Dispersal Device Plume Modeling and 
Deposition Assessment in Washington 

During the FSE, there were multiple FSL agencies that had responsibilities for collecting data. 
The data was then sent to one or more locations to be compiled and analyzed. Once the analyses 
were complete, information was provided to top officials to assist in their decision-making. 
However, there were critical data collection and coordination challenges that impacted the 
response to the RDD attack in Seattle, to include the provision of timely, consistent, and valid 
information to top officials. 

Significant findings from the FSE include the following: 

• The coordination of onsite and offsite data collection by multiple agencies at FSL levels 
of government needs to be improved. The FSE highlighted the many radiological data 
collection assets that exist at all levels of government. FSL agencies and departments, 
therefore, need to be educated about the importance of coordinating the data collection 
process, and to work with the Federal Radiological Monitoring and Assessment Center 
(FRMAC) to ensure that coordination takes place during radiological emergencies. The 
development of the NRP will more clearly delineate the data collection and coordination 
processes in the future; 

• The development and distribution of multiple radiological plume analysis products — 
including plume model prediction overlays and empirical deposition/foolprint maps — to 
decision-makers needs to be better coordinated. Different FSL agencies and jurisdictions 
used one or more plume models to generate predictions. Each jurisdiction also developed 
its own data products based upon separate and sometimes conflicting empirical data. As 
a result, Seattle, King County, and Washington State top officials had different or 
conflicting information upon which to base their decisions. In addition, several Federal 
agency and department headquarters developed their own plume predictions to make 
internal assessments concerning a.ssets that might be required. Conflicting predictions 
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• There is a need for additional education among both responders and decision-makers as 
to the timing and value of the different types of information following a radiological 
incident. The value and limitations of plume models and other analysis products are not 
widely understood. Importantly, it appears as though few decision-makers were 
informed of the limited usefulness and lifecycle of plume models. Plume models provide 
a prediction of where the material in the explosion will travel. They can be useful in 
assisting decision-makers in making preliminary decisions regarding likely areas of 
contamination. Once actual data from the incident is collected and evaluated, the value 
of plume models diminishes. Once responders learn what really is out there and where it 
is, predictions alone become less important. However, predictions updated with initial 
measurement data can be useful in estimating protective actions in areas that have not yet 
been surveyed, or in areas that have been contaminated below the measurement threshold 
of available instruments; and 

• The Homeland Security Council is leading an interagency effort to remedy the plume 
modeling process deficiencies noted during the exercise.V 

E. Play Involving the Strategic National Stockpile 

The activation, requests for, deployment and distribution ot the Strategic National Stockpile 
(SNS) were extensively played during the FSE. The exercise tested the ability of all levels of 
government to make decisions, allocate resources, coordinate and communicate, and inform the 
public regarding this critical SNS resource. TTie state of Illinois tested its ability to break down 
and secure the antibiotic stocks, and local jurisdictions tested their abilities to distribute supplies 
of antibiotics to their first responders and citizens. Overall, the request, receipt, breakdown, 
distribution, and dispensing of the SNS during the FSE were completed successfully. Some 
components of the SNS were not tested durmg the exercise. Some aspects of the requesting 
process exercised in T2 presented specific challenges. 

Significant findings from the FSE include the following: 

• Determining a prophylaxis distribution policy for first responders and citizenry across 
local Jurisdictions was challenging. This was due, in part, to the enormous logistical 
challenges of distributing medications to a large metropolitan area, as well as the very 
real limitation of the amount of medication that was immediately available. Determining 
a prophylaxis distribution policy was also challenging due to the need to factor in 
anticipated public reaction if the general citizenry were not given access to the 
medication; 

• Contradictwy information complicated decision-making with respect to the allocation of 
the SNS. Decision-makers experienced difficulty determining the amounts in local 
stockpiles; how much the State had and how its amount would be allocated; and how 
much would be coming from the SNS, when it would arrive, and how much each 
jurisdiction would receive; 

• Inconsistent information was given by different jurisdictions as to who should seek 
prophylaxis and when, the locations of the suspected plague release sites, and whether 
one should stay home or seek medical attention; and 


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• The Homeland Security Council is leading an interagency working group to resolve the 
mass prophylaxis issues that arose during the exercise. 

F. Hospital Play in the Illinois Venue: Resources, Communications, and Information 
Sharing during a Public Health Emergency 

During the FSE, 64 hospitals in the Illinois venue participated in the exercise, making it one of 
the largest mass casualty exercises ever undertaken. This aspect of T2 presented an 
unprecedented opportunity to examine the coordinated efforts of the medical and public health 
communities to react to and control the spread of a disease outbreak, specifically an outbreak 
initiated by a bioterrorism attack. Because of the large number of participating hospitals, 
challenges regarding communication and the management of resource requirements were 
significant. 

Significant findings from the FSE include the following: 

• During the FSE. the lack of a robust and efficient local emergency communications 
infrastructure was apparent. Communications heavily relied upon tele{rfiones and faxes 
for data transmission. The unanticipated large call volume was the greatest problem. 
The phone system in at least one location was overwhelmed, requiring three amateur 
radio operators to maintain communications connectivity. Facsimile communications 
were also subject to transmission and receipt problems due to call volumes. "Blast fax 
transmissions” took up to two hours to conqtlete. In addition, information was often 
copied manually to a form. The form was then faxed (in some cases degrading its 
readability) to a collection point, where it was then manually tabulated on another form, 
and then entered into an information system for transmission. This process significantly 
increases potential errors; and 

• Resource demands challenged hospitals throughout the FSE. These included short 
supplies of isolation and negative pressure rooms, as well as staff and bed shortages. 
Hospitals employed a number of solutions to these problems including activating staff 
phone trees to recall medical personnel; using extra conference rooms, lobbies, and 
Clinical Decision Units (closed units) as isolation wards; and using same-day surgery, 
radiology, and endoscopy labs, as well as an offsite tent, as negative pressure (i.e., 
disease containment) rooms. 

G. Decision-Making Under Conditions of Uncertainty: The Plague Outbreak in the Illinois 
Venue 

During a disease outbreak, whether naturally occurring or initiated by an act of terrorism, 
decision-makers must make effective response decisions. Officials rely upon scientists, medical 
doctors, and the public health system to provide them with the best scientific information. It is 
this information that decision-makers must use to formulate answers within the context of the 
logistical, political, social, public health, and economic aspects of a response. This is especially 
difficult following terrorist attacks due to the enormous media and time pressures that decision- 
makers will operate under. During the FSE, public health officials initially were uncertain as to 
the extent and possible duration of the plague epidemic. This produced an environment where 
officials had to make decisions without the benefit of positive-proof information. 

Significant findings from the FSE include the following: 


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• Coordination processes between agencies and across jurisdictions regarding 
epidemiological model predictions and patient data need to be improved. In fact, 
information about some modeling efforts was not provided to all operations centers 
during the FSE; 

• There needs to be an enhanced understanding of the implications of long-term patient 
load during a bioterrorism incident. Two issues of concern are: (1) a lack of confidence 
in the patient data, and no clear way to model the long-term effects in the face of poor 
patient data; and (2) a lack of long-term exercise play — the FSE concluded before the 
extensive scale of the outbreak was apparent; 

• During the early stages of an outbreak, decision-makers are likely to see reports about 
only the early presenters, not the full number of exposed persons. It is absolutely critical 
to determine rapidly the scale of the outbreak. This is especially true in cases of potential 
bioterrorism where traditional epidemiological curves could be multiplied by multiple, 
continuing, or widespread initial exposures; and 

• The Homeland Security Council is leading an interagency effoil to resolve mass care and 
medical surge capacity issues that arose during the exercise. 

H. Balancing the Safety of First Responders and the Rescue of Victims 

During incidents when victim survival is dependent upon the timeliness of medical treatment, 
first responders typically initiate victim rescue and removal as rapidly as possible, while incident 
commanders manage responder safety with an ongoing risk-benefit analysis. However, when 
faced with an emergency that potentially involves WMD, first responders face a greater potential 
of becoming casualties themselves. Given the uncertainly surrounding the simulated RDD 
explosion during the FSE, even when many of the responders artificially had the knowledge that 
it was a radiological incident, the incident commander had to take precautions to ensure that the 
responders were safe. However, a number of public health officials and data collectors at the 
incident site, many of whom were subject matter experts, expressed concern about the time it 
took to triage, treat, and transport victims. 

Significant findings from the FSE include the following: 

• Rescue operations at the RDD incident site highlighted the need for more frequent, 
informational communication between incident command and hospital control. Incident 
commanders may need to be more proactive in providing information. While hospital 
control was aware that radiation had been detected at the incident site, there is no 
indication in the data analyzed that incident command or the medical group at the 
incident site communicated with hospital control to explain the need to conduct a more 
detailed risk-benefit analysis before rescue operations could commence. In addition, 
hospital control was unaware of the periodic halts to rescue operations that occurred 
during the initial hours of the exercise response due to both the suspected and simulated 
presence of secondary explosive devices; and 

• The public health and medical communities, the media, and the general public should be 
educated on the unique considerations that must be factored into rescue operations 
following a terrorist WMD attack. Considerations non-responder communities should be 
aware of are the need to balance responder safety and rescue efforts and the specific 


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practices rescuers employ when responding to critical situations, such as the potential for 
secondary explosive devices in or around an incident scene. The public health and 
medical communities should be made aware of the need for incident command to conduct 
a detailed risk-benefit analysis prior to the start of rescue operations. Finally, a consistent 
message to the public from incident command, public health, and medical communities is 
critical. 

VI. Six Core Areas of Analysis 


A. Emergency Public Policy and Decision* *Making 

Emergency Public Policy and Decision-Making encompasses the unique challenges, difficulties, 
and nuances faced by top officials in the initial aftermath of a terrorist WMD attack. During the 
FSE, top officials were faced with two critical decisions that have not yet occurred in the real 
world: (1) elevations of the threat status to Red by City, County, and Federal authorities; and 
(2) a request for and issuance of Presidential Declarations for RDD and bioterrorism attacks. 

Significant findings from the FSE include the following: 

• Making decisions under conditions of uncertainty, when information is rapidly changing 
or unknown, remains a significant challenge. Decision-makers experienced challenges 
obtaining reliable, validated, and timely information. In the case of bioterrorism, the 
parameters are difficult to define, and the full extent of the effects from such an attack 
may be unknown. During a physical disaster, such as the case of an RDD blast, the 
parameters can often be roughly determined, but life-saving and public safety decisions 
may be required before perfect information is available; 

• Greater understanding is needed of tbe mid- to long-term impacts of multiple terrorist 
attacks. The FSE did not play out long enough for participants to face the long-term 
economic, health, social, or political implications of the scenario. To more thoroughly 
examine long-term issues, the private sector should be encouraged to participate more 
extensively in future TOPOFF exercises and events; and 

• The international aspect of T2 and the active participation of the Canadian Government 
represented a significant new element of the TOPOFF Exercise design. The cross-border 
play expanded the scope of decisions faced by domestic top officials during the FSE and 
enhanced the realism of the exercise. 

B. Emergency Public Information 

Emergency Public Information encompasses the unique public infonnation challenges and 
implications faced by top officials and their support staff in the midst of a terrorist WMD attack. 
Emergency public information was a dominant issue of TOPOFF 2000 and remained one 
throughout the T2 seminars, LSG, and FSE. T2 provided a unique opportunity for jurisdictions 
at all levels to exercise, experiment with, and improve upon critical public information strategies. 
This exercise was an opportunity for participants to showcase the value of concepts, such as 
regional Joint Information Centers (JICs), that may be expanded for more comprehensive 
coordination at both broader FSL levels and in environments where people cannot be physically 
co-located. 


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Participants commented that future TOPOFF Exercises should continue to allow participants to 
experiment in the emergency public information arena, which should include an aggressive 
news-gathering element and a realistic mock-public response to further challenge exercise 
participants. 

Significant findings from the FSE include the following: 

• Speaking with one voice proved to be one of the greatest emergency public information 
challenges during the FSE. JICs were implemented in both venues and helped to unify 
messages, but not all information was coordinated through the JICs. In both venues, 
however, the DHS PFO emphasized and worked for a consistent Federal message that 
was also consistent with the State and local messages; 

• Official messages to the public regarding protective action guidelines were often 
incomprehensive or conflictive; 

• Rumors abounded during the FSE. Determining which statements were true proved to be 
a significant challenge for T2 participants. Improving official channels of 
communication would help to counter and confirm rumors. Ensuring accurate 
information depends upon having structured, well-defined, and robust information flow 
strategies, where information is accepted from predefined validated sources. Such 
strategies exist in numerous policies such as the INRP, but implementation of them 
remains a challenge. Although the exercise did not play out long enough in either venue 
to establish how the long-term role of the PFO might affect information flow, during a 
disaster, the PFO role has the potential to strengthen and streamline the movement of key 
information between the State and local governments and Federal agencies; 

• Even though the need for pre-coordinated information packages was mentioned 
throughout the seminars and during the LSG, many agencies lacked a full set of pre- 
coordinated, off-the-shelf packages prior to the FSE; and 

• DHS has led an interagency effort to successfully remedy the incident communications 
deficiencies noted during TOPOFF 2000. Results include an interagency-approved 
incident communications strategy, hotline, subject matter expert reach-back, and 
improved FSL incident communications processes and protocols. 

C. Communications, Coordination, and Connectivity 

Conmunicarions. Coordination, and Connecfiviry encompasses the challenges that result from 
information exchange across all levels of government, the information flow that supports 
decision-makers, and the electronic means by which information is shared. Communications, 
coordination, and connectivity issues probably present the greatest challenges when responding 
to a mass casualty incident, especially one involving WMD. During the FSE, several challenges 
emerged in these three dimensions of information exchange. A lack of coordination was the 
primary communication challenge observed during the FSE. 

Significant findings from the FSE include the following: 

• There were numerous instances when participants experienced difficulties obtaining or 
validating information. In the absence of a commonly understood process for official 
notifications, agencies had difficulty confirming the status of the HSAS Threat Level for 


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several hours. Also, agencies spent substantial time confronting rumors regarding, 
among other misinformation, transportation closures, patient numbers in both venues, and 
casualty figures at the RDD scene. Some agencies attributed these problems to too many 
official reporting channels, where various agencies exercised not only their own 
independent procedures but also redundantly requested updates from agencies; 

• Inconsistent language was another communication challenge during the FSE. In 
Washington State, confusion arose as many participants interchangeably used the term 
casualties to mean fatalities or injured people, or both. Similarly, the nonspecific 
references to plague in internal agency communications resulted in at least one instance 
when a public health person gave advice that applied to Bubonic Plague rather than 
Pneumonic Plague; 

• Officials also remarked on the critical importance of having technical data translated into 
non-technical language to support decision-making and risk communications; 

• Data collection and coordination issues challenged both the Washington and Illinois 
venues. In Washington, the primary coordination challenges involved the collection and 
reporting of radiological ground data and the apparent lack of a unified command 
structure during the early stages of the response at the RDD site. In Illinois, the greatest 
coordination challenges involved the collection of information and the data flow 
requirements among the 64 hospitals, the five POD hospitals (the five lead hospitals for 
coordinating disaster medical response in a specific region upon activation of the 
emergency medical disaster plan by Illinois Operations Headquarters and Notifications 
Office (lOHNO)), and three separate but interrelated statewide organizations: Illinois 
Department of Public Health (IDPH), lOHNO, and the Illinois State Emergency 
Operations Center (EOC): 

• The FSE provided opportunities for participation from some organizations not typically 
included in a response, and also encouraged some organizations to participate in new 
ways. For example, the American Red Cross participated in the Federal Joint Operations 
Center (JOC) and Bank of America co-located an EOC with the Federal Reserve. 
Further, participants reported that the T2 building-block process was extremely valuable 
in helping them to develop new or stronger relationships with their colleagues at all 
levels; and 

• Connectivity challenges impacted the ability of technical experts, agencies, and 
jurisdictions to communicate effectively. Hospitals and the medical system lack robust 
Internet-based communications systems in many cases and overwhelmingly rely on 
phones and faxes for transmitting and tracking critical patient and resource information 
which is extremely inefficient. In Illinois, organizations reported their fax machines were 
unreliable due to mechanical breakdowns and an inadequate number of staff to monitor 
them. Also some machines were reported to be in locked rooms. Likewise, the lack of 
verified phone numbers caused communication delays while emergency personnel spent 
critical time looking for the correct numbers to report emergency data. In Washington, 
the Department of Health Radiation Monitoring and Assessment Center (RMAC) and 
FRMAC experienced .significant connectivity challenges that impacted their ability to 
distribute data and data products, respectively, to decision-makers, subject matter experts, 
and responders. 


SR-13 



T2AAR 


T2 


D. Jurisdiction 

Jurisdiction encompasses the issues, conflicts, or gaps in authorities and the assumptions that 
may arise when policies and agreements are put into practice under the uniquely challenging 
conditions of a terrorist WMD attack. The FSE demonstrated that jurisdictional policies and the 
extent to which they are understood by various entities drive and influence every element of 
response. Participants at all levels of government continue to state that exercises such as 
TOPOFF remain one of the most effective means to explore the operational implications of these 
jurisdictional policies and refine authorities that may appear clear on paper but which lack clarity 
when implemented under the complex conditions of a disaster. 

Significant findings from the FSE include the following: 

• Throughout the T2 cycle, the primary jurisdictional question evolved from “who is in 
charge” to “who is in charge of what.” During the FSE, there was some confusion with 
the multiple, and sometimes overlapping, authorities that were driving the disaster 
response. For example, in Illinois there were many discussions concerning the 
jurisdiction over the decontamination process and the facilities where the biological agent 
was released (the United Center, O’Hare International Airport, and Union Station). 
Similar questions arose in the Washington venue regarding the management of the long- 
term impacts of the radiological contamination; 

• The FSE provided an opportunity to explore jurisdictional issues involving DHS. For 
example, there was uncertainty between the Transportation Security Administration and 
the Federal Aviation Administration regarding the authority to close and reopen airspace 
and issue temporary flight restrictions. Issues also arose regarding the activation, 
requests for. deployment, and distribution of the SNS, where both HHS and DHS are 
involved in these processes. Futth«more, questions arose regarding the relationship 
between HHS and DHS during a Public Health Emergency, and how expertise and health 
and medical assets — which are now split between DHS and HHS — are used and 
managed. The FSE helped to highlight areas where the role of the PFO as it relates to 
FEMA officials needs additional clarification. Lastly, the Environmental Protection 
Agency noted the need to clarify its authorities relative to DHS. specifically noting 
development and maintenance of health and safety plans; and 

• The authority to release information can be especially problematic when a disaster 
crosses jurisdictional boundaries, as was the case during the FSE with both the RDD and 
bioterrorism attacks. Organizations at State and local levels repeatedly expressed 
concerns about Federal organizations releasing information that the Stale and local 
organizations believed they should have released instead. 

E. Resource Allocation 

Resource Allocation encompasses the challenges that require decision-makers to weigh 
conflicting needs and determine how best to allocate limited resources. Conflicting resource 
needs can challenge decision-makers within a single agency, or can force decision-makers from 
different agencies and departments to work together under stressful and time-constrained 
conditions to decide how best to manage critical resources that are in short supply. Often the 
solution requires individuals and organizations to use unconventional methods. 


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T2 


While the scenario did not fully stress the Washington venue resources and the FSE ended before 
the number of plague patients overwhelmed the Chicago area medical and public health 
capabilities, a number of resource allocation issues and “best practices” emerged. 

Significant findings from the FSE include the following: 

• State and local participants were often not aware of which Federal resources were 
available and how to access them. State and local emergency managers and responders 
would benefit from an “Emergency Response Knowledge Base,” or Procedural Flow, that 
described all Federal assets, helped Stale and local officials identify those assets that 
would best meet their needs in an emergency, and explained how to request the response 
assets; 

• A “one stop shop” for tracking the status of Federal assets that have been activated or 
deployed during an emergency does not exist. FEMA currently tracks and reports the 
usage of Federal assets in a disaster through its Mission Assignments and Situation 
Reports, but distribution of these reports is fairly inefficient. A Web-based, searchable 
knowledge base of all available Federal resources and their status (potentially expanded 
to include State and local resources) may be helpful in this regard, particularly when 
resources are stressed; 

• Having a contingency plan for the receipt and distribution of the SNS contributed to a 
fairly smooth-running process in Illinois. In contrast, shipment and distribution of the 
National Pharmaceutical Stockpile (the previous name for the SNS) did not transition as 
smoothly in the TOPOFF 2(X)0 exercise. In part, this reflects the tremendous investments 
in planning and preparedness that have occurred in State and local public health 
departments since the fall of 2001; 

• Participants utilized unconventional strategies to meet resource demands. They did this 
by relying on unconventional sources of support and by intervening with executive orders 
that exempt individuals from repercussions that were often legal and which would 
otherwise prevent them from providing services; and 

• Decision-makers anticipated future demand. In Washington, several assets were placed 
on standby in case they were needed at another incident site. Illinois emergency 
managers and public health officials developed a plan to deal with the limited supply of 
medication and anticipated potential hospital surge requirements that the growing 
epidemic would require. In Washington, D.C., the DHS Emergency Preparedness and 
Response Directorate worked on a plan to distribute the SNS to other states that requested 
it, recognizing the inevitable spread of Pneumonic Plague cases outside Illinois. 

F. Anticipating the Enemy 

Anticipating the Enemy encompasses the unique considerations that influence decision-making 
when there is a potential enemy threat. The existence of an enemy makes the response to a 
terrorist attack qualitatively different from the response to any natural or conventional disaster. 
For example, the desire to keep the terrorists from gathering information regarding response 
plans works against the desire to keep the public informed. 

Significant findings from the FSE include the following: 


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T2 


• There were a number of responder and top official activities that demonstrated a keen 
awareness of potential follow-on attacks. In Washington, the National Guard Civil 
Support Team was released from the incident site in part so that they would be available 
to redeploy in the event of another terrorist attack. In the Chicago area, authorities 
increased surveillance and decreased parking and deliveries at likely terrorist targets after 
the RDD explosion in Seattle. At the interagency venue. HHS, DHS, the Centers for 
Disease Control and Prevention, and others gave considerable thought to the need to 
reserve the SNS and other resources, specifically mentioning that Chicago might not be 
the only city to have been attacked with Pneumonic Plague; 

• Many agencies stated that they either were not playing against an enemy or that it was the 
responsibility of others (e.g., the Federal Bureau of Investigation (FBI) and the JOC) to 
consider the enemy. However, when participating in a response, agencies should be 
aware that their responders are at risk. The loss of responders in additional attacks could 
seriously impair an agency’s response capability, not to mention how such a loss would 
impact the morale of other responders and the public at large; and 

• While an active opposing force, known as a Red Team, was limited in scope during the 
FSE, even its limited presence was beneficial to employing a more robust Red Team in 
future exercises. 

VIL Exercise Design and Conduct Lessons Learned 


The T2 AAC attendees and exercise participants identified several lessons learned relating to 
exercise design and conduct. Considerations for developing the following areas may benefit the 
success of succeeding TOPOFF Exercises: 1) planning and participation, 2) exercise artificiality, 
3) scenario scripting, 4) the role the Virtual News Network (VNN), 5) a functional Web-based 
control capability, and 6) exercise security. 

Other considerations worth investigating are the intelligence development and management 
processes, the guidelines for producing and publishing exercise documents, the standards for 
determining official exercise time, and methods for empowering the venue design and 
coordination teams. 

VIII. Conclusions 


T2 was an innovative, useful, and successful exercise built upon the accomplishments of 
TOPOFF 2000 and was the first national combating terrori.sm exercise conducted since DHS was 
established. As a result, T2 provided a tremendous learning experience for both the new DHS 
and the Federal agencies now working with DHS during a response to domestic incidents. In 
addition, the experience in Washington and Illinois provided important lessons regarding FSL 
integration. These lessons are valuable to other states and localities as they work to train, 
exercise, and improve their own response capabilities. 

T2 involved the play of new agencies and entities within DHS (e.g., the Transportation Security 
Agency, the PFO, and the Crisis Action Team). 

• The PFO concept was tested in both exercise venues. While this position has the 
potential to assist greatly with the coordination of Federal activities across the spectrum 


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T2 


of the response, T2 results also indicated that the roles and responsibilities of the PFO 
need to be clarified with respect to those of the FBI SAC, the FEMA RD, and the FCO. 
In addition, the PFO requires an emergency support team with the flexibility and 
expertise to provide support across the full range of homeland security operations. 

T2 represented the first time (real or notional) in which the HSAS Threat Level was raised to 
Red. 

• Valuable experience was gained as the Secretary of DHS, in concert with the Homeland 
Security Council, first raised selected areas of the country and then the whole country to 
Threat Level Red. In addition, local jurisdictions raised their own threat levels to Red. 

T2 involved an extraordinary sequence of two Presidential Declarations wrapped around a Public 
Health Emergency declaration by the Secretary of HHS. 

• The Presidential declarations were for a major disaster in the Washington venue and an 
emergency in the Illinois venue. These two declarations illustrated some of the subtleties 
of the Stafford Act that may not have been fully appreciated before the exercise; for 
instance, a bioterrorism attack does not clearly fit the existing definition of disaster as 
defined by the Act. The Secretary of HHS, acting on authorities through the Public 
Health Service Act and in consultation with the region, declared a Public Health 
Emergency. This permitted HHS to authorize the use of Federal assets (with costs 
covered by HHS). 

Planning and development of the NRP and National Incident Management System should take 
advantage of the TOPOFF Exercise Series. 

• Communication and coordination issues drove the course and outcome of critical public 
policy decisions, from raising the threat level to the various disaster/emergency 
declarations, and from the determination of exclusion zones to the reopening of 
transportation systems. To the extent that there were problems in these areas, 
communication issues were likely the primary cause; and 

• T2 showed that how people believe communications and coordination should work as 
based upon policy is often not how they work in reality. What may appear to be clearly 
defined processes — such as requesting the SNS — in practice become much more 
difficult. 

With the active participation of 64 hospitals in the Chicago area responding to the notional 
bioterrorism attack, T2 represented one of the largest hospital mass casualty exercises ever 
conducted. 

• T2 represented a significant experiment in communications and coordination for the 
public health and medical communities. In particular, the massive amounts of 
communication required to track resource status (beds, specialized spaces, and medical 
equipment), and the cumbersome procedures and insufficient electronic means to do so in 
many cases, taxed hospital staff; 

• T2 did not allow full exploration of the impacts of mass casualties on the medical system. 
Much less than half of the infected population was visible to the medical system at the 
conclusion of the exercise: and 


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T2 


• While there were a number of attempts to estimate the potential scope of the outbreak, the 
focus of most activities appeared to be on the cases that were presented to the health care 
system. It should be noted that HHS was working actively during the FSE to identify the 
resources that would be required to deal with the infected population. 

T2 Illinois play also involved an extensive SNS request and distribution component. 

• Although the actual distribution process appeared to go quite well, there was some 
confusion over the procedures and processes for requesting and receiving the SNS. The 
SNS Operations Center coordinated the stockpile deployment through the FEMA 
Emergency Preparedness and Response Director. Additionally, senior-level consultation 
occurred between DHS and HHS via Video Teleconference and direct communication; 
and 

• The jurisdictions in the Chicago area were forced to confront important decisions about 
how the stockpile (and local assets) would be divided and who would be among the first 
population groups to receive prophylaxis. The discussions and decision-making 
involved, as well as the challenges in coordinating public infcumation, are worthy of 
study by other metropolitan areas for the lessons they provide. 

DHS should consider the integration of existing response policies and plans into the NRP. 

• States are familiar with and have built their response plans to coincide with Federal assets 
and plans using similar agency and department structures and language; 

• Federal agencies are satisfied with the language, authorities, and relationships outlined in 
existing plans such as the Federal Radiological Emergency Response Plan and the 
Federal Response Plan; and 

• As the NRP undergoes development, the integration of response plans and policies merit 
consideration — particularly where existing plans are considered effective for emergency 
response. 

T2 involved more intense and sustainwl top officials play than occurred during TOPOFF 2000. 

• Of particular note was the involvement of DHS (which had been in existence for only a 
little more than ten weeks prior to the exercise), the DHS Secretary, and other senior 
civilians: 

• HHS operated the Secretary’s Command Center for 24 hours per day throughout the 
exercise with extensive play at the Assistant Secretary- and Operating Division Director- 
levels. The Secretary was actively involved, and since one venue involved substantial 
public health and medical play, the active participation of HHS was critical to the success 
of the exercise; and 

• In both Washington and Illinois, the offices of the mayors, county executives, and 
governors were well-represented throughout the exercise by either the elected officials 
themselves or high-level policy-makers in respective administrations. In particular, the 
Mayor of Seattle participated substantially in the FSE, providing local top leadership that 
greatly contributed to the realism of play and to a greater appreciation of the local 
challenges and perspectives in a national WMD incident. 


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T2 


T2 represents a foundational experience to guide the future development of the TOPOFF 
Exercise Series. 


• Because of the extensive data collection process and the effort to make T2 findings both 
well-documented and traceable through a detailed reconstruction of the exercise events, 
T2 represents a baseline upon which subsequent TOPOFF exercises can build and to 
which they can be rigorously compared; 


T2 demonstrated the value of the international, private sector, and nonprofit perspectives 
and roles in response to WMD terrorism. Future exercises will, no doubt, expand upon 
these elements by broadening the participation of all these sectors; 

Red Team activities during T2 provided ground rules for the involvement of a simulated 
active enemy threat in future exercises. This play should also be expanded in future 
exercises, as it represents one of the fundamentally different challenges responders face 
in a terrorist WMD disaster relative to any natural or conventional disaster; and 

The success of the VNN and widespread participant feedback regarding the desire for 
additional challenges in the area of public informWon^uggest that future exercises 
should include a more aggre.ssive mock-media element with a more aggressive news- 
gathering function that includes mock-press conferences. 




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PARTICIPATING AGENCIES LIST 


United States Federal Departments and Agencies 

American Red Cross (ARC) 

Bureau of Alcohol, Tobacco, Firearms, and Explosives (ATF) 

Centers for Disease Control and Prevention (CDC) 

Defense Threat Reduction Agency (DTRA) 

Department of Agriculture (USDA) 

Department of Defense (DoD) 

Department of Energy (DOE) 

Department of Health and Human Services (HHS) 

Department of Homeland Security (DHS) 

Department of Housing and Urban Development (HUD) 

Department of Justice (DOJ) 

Department of Labor (DOL) 

Department of Navy (DON) 

Department of the Interior (DOI) 

Department of State (DOS) 

Department of Transportation (DOT) 

Department of Veterans Affairs (VA) 

Environmental Protection Agency (EPA) 

Federal Bureau of Investigation (FBI) - Critical Incident Response Group (CIRG) 

FBI - WMD Countermeasures Unit 

Federal Aviation Administration (FAA) 

Federal Emergency Management Agency (FEMA) 

General SeOi'ices Administration (GSA) 

Institute for Security Technology Studies (ISTS) 

Joint Forces Command (JFCOM) 

National Aeronautics and Space Administration (NASA) 

National Imagery and Mapping Agency (NIMA) 

National Reconnaissance Office (NRO) 

National Security Council (NSC) 

National Weather Service (NWS) (Department of Commerce) 

Nuclear Regulatory Commission (NRC) 

Occupational Safety and Health Administration (OSHA) 


PAL-l 




















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United States Federal Agencies and Organizations (Continued) I 

Postal Inspection Service (U.S. Postal Service [USPS]) 

Small Business Administration (SBA) 

Social Security Administration (SSA) 

Technical Support Working Group (TSWG) 

Transportation Security Administration (TSA) 

U.S. Coast Guard (USCG) 

U.S. Customs Service (USCS) 

U.S. Geological Survey (USGS) 

U.S. Secret Service (USSS) 

Canadian Agencies 

Agriculture and Agri-Food Canada (AAFC) 

British Columbia Ministry of Health EOC (BCMOH) 

British Columbia Provincial Emergency Program (BCPEP) 

Canadian Coast Guard (CCG) 

Canada Customs and Revenue Agency (CCRA) 

Canadian Food Inspection Agency (CFIA) 

Canadian Nuclear Safety Commission (CNSC) 

Canadian Security Intelligence Sen/ice (CSIS) 

Citizenship and Immigration Canada (CIC) 

Department of Justice (DOJ) 

Department of Defense (DoD) 

Department of Foreign Affairs arxl International Trade (DFAIT) 

Environment Canada (EC) 

Health Canada (HC) 

Industry Canada (1C) 

Office of Critical Infrastructure Protection and Emergency Preparedness (OCIPEP) 

Privy Council Office (PCO) 

Public Works and Government Services Canada (PWGSC) 

Royal Cstfiadian Mounted Police (RCMP) 

Solicitor General (SGC) 

Transport Canada (TC) 


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State and Local Agencies 

American Red Cross of Greater Chicago (ARCGC) 

Chicago Department of the Environment (CDOE) 

Chicago Department of Public Health (CDPH) 

Chicago Fire Department (CFD) 

Chicago Office of Emergency Management and Communications (OEMC) 

City of Bellevue 

Cook County Sheriff’s Office (CCSO) 

Cook County Sheriff’s Office Emergency Management Agency (CCSO EMA) 

Cook County Department of Public Health (CCDPH) 

DuPage County Office of Emergency Management (DCOEM) 

DuPage County Health Department (DCHD) 

Illinois Department of Public Health (IDPH) 

Illinois Emergency Management Agency (lEMA) 

Illinois Hospital Association (IHA) 

Illinois Office of the State Fire Marshal 

Illinois State Fire Chiefs Association 

Illinois State Police (ISP) 

Illinois Commerce Commission (ICC) 

Illinois Department of Transportation (IDOT) 

Illinois Department of Human Services (IDHS) 

Kane County Office of Emergency Management (KCOEM) 

Kane County Health Department (KCHD) 

King County Fire Chiefs Association (KCFCA) 

King County Government (KCG) 

King County Office of Emergency Management (KCOEM) 

King County Police Chiefs Association (KCPCA) 

Public Health - Seattle and King County 

Lake County Emergency Management Agency (LCEMA) 

Lake County Health Department (LCHD) 

Lake County Fire Department Specialized Response Team 

Metropolitan Chicago Healthcare Council (MCHC) 

Office of the Governor of the State of Illinois 

Office of the Governor of the State of Washington 

Office of the Mayor of the City of Chicago 


PAL-3 



T2AAR 


State and Local Agencies (Continued) 


Office of fhe Mayor of the City of Seattle 
Port of Seattle 

Seattle Fire Department (SFD) 

Seattle Emergency Management (SEM) 

Seattle Police Department (SPD) 

Washington State Department of Agriculture (WSDA) 
Washington State Department of Ecology (WSDE) 

Washington State Department of Health (WSDH) 

Washington State Department of Information Services (WSDIS) 


Washington State Department of Transportation (WSDOT) 
Washington State Emergency Management Department (WSEMD 


Washington State Ferries (WSF) 
Washington State Patrol (WSP) 











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Top Officials (TOPOFF) 
Exercise Series: 







TOPOFF 2 (T2)' 

After Actioit^^orf' 

^^epar^|for 

U.S. DepartmSitwf.Honieland Security 
Office for Domestic Preparedness 
by AMTI and the CNA Corporation 
Under Schedule Number GS-10F-0324M, 
Order Number 2003F028 




! 



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T2AAR 


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TABLE OF CONTENTS 


Summary Report I SR- 1 
Participating Agencies List I PAL- 1 
Administrative Handling Instructions I 


I. 


II. 


III. 

IV, 


V. 


Introduction I I 

A. T2 Goals I 

B. T2 Open Exercise Design and Concept 

C. Significant Aspects of T2 2 

D. Overview of the AAR 3 

Background I S 

A. Public Law Authorizing the Top Officials Exe^i 

B. Overview of FSL Agency Objectives for T2 

C. TOPOFF 2{KK) 7 

D. Related Real-World Events 8 

E. The T2 Building-Block Events 

F. Exercise Scenario 10 

G. Evaluation Methodology 12 


Reconstruction of the FSE 








47 


Artificialities I 25 

A. Inherent Exercise Design Artificialities 25 

B. Artificialities Specific to tte T2 Design Process 27 

C. Artificialities That Ai^ [>uring Exercise Play 29 

Special Topics I 31 

A. Alerts and Alerting: 

The Elevation of the HSAS Threat Condition to Red 33 

B. Declarations and Proclamation of Disaster and Emergency 

C. Department of Homeland Security Play in T2: 

The Role of the Principle Federal Official 55 

D. Data Collection and Coordination: 

Radiological Dispersal Device Plume Modeling and Deposition 
Assessment in Washington 63 
Play Involving the Strategic National Stockpile 91 
Hospital Play in the Illinois Venue: 

Resources, Communications and Information Sharing 
during a Public Health Emergency 105 

G. Decision-making under Conditions of Uncertainty: 

The Plague Outbreak in the Illinois Venue 121 

H. Balancing the Safety of First Responders and the Rescue of Victims 


E. 

F. 


137 


iii 




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T2 


149 


VI. Analysis of the Six Core Areas I 147 

I. Emergency Decision-Making and Public Policy 

J. Emergency Public Information 161 

K. Communications, Coordination, Connectivity 181 

L. Jurisdiction 191 

M. Resource Allocation 197 

N. Anticipating the Enemy 203 

VI. Comparison to TOPOFF 2000 I 207 

A. Design 207 

B. Participants 208 

C. Evaluation, and the Data to Make It Possible 208 

D. Findings 208 

1 , 

VII. Exercise Design and Conduct Lessons Learned I 2J3 
A. Exercise Design and Conduct Comments 2r3. 


VIII. Conclusions I 217 

IX, Glossary 1 221 


ANNEX A TOPOFF 2 Master Reconstruction 











ANNEX B Department of Stale: 

TOPOFF 2 Iniemationa(/.Cana<]fSn After Action Report Excerpt 


ANNEX C National 


\ 

lal (^{ntal Region: y 

-I- AX’. A 


FunctionahExenis^^er Action Report 




ANNEX D TOPOFF 2 CyberEx After Action Report 






IV 



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T2 


ADMINISTRATIVE HANDLING INSTRUCTIONS 


1. The title of this document is Top Officials (TOPOFF) Kxercise Series: TOPOFF 2 (72) 
After Action Report. 

2. This document should be safeguarded, handled, transmitted, and stored in accordance 
with appropriate Canadian. U.S. Department of Homeland Security (DHS), U.S. 
Department of State (DOS), the State of Illinois, the State of Washington, and local/city 
security directives. This document is marked For Official Use Only (FOUO). and 
information contained herein has not been given a security classification pursuant to the 
criteria of an Executive Order, but this document is to be withheld from the public 
because disclosure would cause a foreseeable harm to an interest protected by one or 
more FOUO exemptions. 

3. Reproduction of this document, in whole or in part, without prior approval of DHS is 
prohibited. 

4. DHS, Office for Domestic Preparedness (ODP), and DOS, the <pffice of the Coordinator 
for Counte rterrorism, cosponsored the T2 Exercise Series. Mr. Theodore Macklin |(W6) 


(b)(6) 


and Mr. Corey Gruber (2 02-514-0284) are the ODP Points of Contact (POCs) 
and [(b»6) I the Office of the Coordinator for Counterterrorism, is 

the POC for international play. 

This report is intended for the iise of Federal. Stale, and local (FSL) officials responsible 
for homeland security. It is intended to improve the FSL plans to prevent and respond to 
weapons of mass destruction by understanding the lessons learned from T2. 


V 


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VI 



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T2 


I, INTRODUCTION 


Top Officials (TOPOFF) 2 (T2) was a congressionally-directed, national combating terrorism 
exercise. It was designed to improve the nation’s domestic incident management capability by 
exercising the plans, policies, procedures, systems, and facilities of Federal, State, and local 
(FSL) response organizations against a series of integrated, geographically dispersed terrorism 
threats and acts. The T2 exercise was co-sponsored by the U.S. Department of Homeland 
Security (DHS), Office for Domestic Preparedness (ODP), and the U.S. Depwtment of State 
(DOS), Office of the Coordinator for Counterterrorism. 

A. T2 Goals 

T2 was driven by four overarching national goals: 

• To improve the nation’s capacity to manage complex/extreme events; 

• To create broader operating frameworks of expert domestic incident management and 
other systems; 

• To validate FSL authorities, strategies, plans, policies, procedures, protocols, and 
synchronized capabilities: and 

• To build a sustainable, systematic exercise process for advancing domestic preparedness. 

As one of the first major projects within DHS, T2 brought together extensive inter-governmental 
and international participation. The U.S7Canadian aspect of T2 was designed to increase 
coordination and communication in response to a weapons of mass destruction (WMD) 
incident.' This cross-border play focused on several bi-lateral goals: 

• To improve U.S. and Canadian top officials’ understanding of the international 
implications of a multi-faceted WMD terrorist incident; 

• To improve top officials’ capability to respond in partnership to the crisis and 
consequence management aspects of a WMD terrorism incident; 

• To build a sustainable U.S./Canadian joint exercise program in support of bi-lateral 
preparedness and response strategies for WMD terrorism incidents; 

• To assess and strengthen partnerships between all organizations, including non-traditional 
partners, involved in responding to a WMD terrorism incident to improve overall crisis 
and consequence management capabilities; 

• To exercise and assess Federal, State/Provincial, and local crisis and consequence 
management plans, directives, and processes for addressing cross-border WMD terrorism 
incidents; and 


' Analysis of international aspects of T2 and U.S./Canadian play during the Full-Scale Exercise is provided in Annex 
B of this report. 


1 




T2AAR 


T2 


• To conduct a joint exercise in accordance with the U.S./Canadian Smart Border 
Declaration and U.S./Canadian Chemical, Biological. Radiological, and Nuclear (CBRN) 
Guidelines. 

B. T2 Open Exercise Design and Concept 

The first TOPOFF exercise (TOPOFF 2000) was a single, no-notice, Full-Scale Exercise (FSE) 
co-chaired by the Department of Justice (DOJ) and the FEMA in May 2000. Unlike TOPOFF 
2000, T2 was designed as an “open” exercise in which participants were introduced to the 
exercise scenario prior to the FSE through a cycle of exercise activity of increasing complexity 
that included: 

• A series of seminars exploring acute response issues; 

• The Large-Scale Game (LSG) that explored mid- and long-term recovery issues; 

• An Advanced Distance Learning Exercise (ADLE) which used s^llite networks to 
support first responder training nationwide; 

• A Top Officials Seminar designed to explore top official response to terrorism incidents 
involving WMD; and 

• An FSE that allowed top officials to join all players in response to a simulated terrorist 
attack with a radiological dispersal device (RDD) in Seattle, Washington and a simulated, 
deliberate release of Pneumonic Plague (Yersinia pesfis) at several locations in the 
Chicago. Illinois, metropolitan area. 

The purpose of the open exercise design was to enhance the learning and preparedness value of 
the exercise through a “building-block” approach, and to enable participants to develop and 
strengthen relationships in the national response community. Participants at all levels have 
stated that this was of enormous value to them. 

C. Significant Aspects of T2 

The T2 exercise was much more than a large-scale. WMD training exercise for civilian agencies; 
as the name TOPOFF denotes, a major component of the exercise was the involvement of top 
officials. The top officials playing in T2 included elected officials, such as governors and 
mayors, as well as non-elected officials who are at 
the apex of homeland security decision-making: 
cabinet members and other agency heads at the 
Federal level; police, fire, emergency management, 
and public health chiefs, among others, at the local 
level; and the directors of statewide agencies, 
including state police and the National Guard. The 
top officials were involved not only for their own 
learning but also to make possible realistic multi-govemment-level play. At the T2 After Action 
Conference (AAC), DHS Secretary Tom Ridge stated that the Homeland Security Council, 
which met repeatedly during the FSE, “dramatically increased its awareness of the nature and 
complexity of top-level issues related to terrorist attacks.” 

The following developments made the T2 FSE a significant national event: 


The TOPOFF process. ..provides the 
nation an architecture upon which 
terrorism preparedness 
responsibilities can be played out, 
tested, and evaluated. 

-DHS Secretary Tom Ridge 


2 




T2AAR 


T2 


• It was the first national exercise conducted since the establishment of DHS; 

• It was the largest peacetime terrorism exercise ever sponsored by DHS or DOS; 

• It involved the play of DHS and the new agencies and entities within DHS, such as the 
Transportation Security Agency, the Principle Federal Official (PFO), and the Crisis 
Action Team (CAT), as well those outside of DHS, such as the Department of Health and 
Human Services (HHS) Secretary’s Emergency Response Team (SERT); 

• It represented the first time — both real and within an exercise — that the Homeland 
Security Advisory System (HSAS) Threat Condition was raised to Red; 

• It represented one of the largest mass casualty exercises to incorporate hospital play’: and 

• It involved intense and sustained top official play. 

• It introduced the concept of a live opposing force (OPFOR) in a national exercise which 
established ground rules for the involvement of a simulated active enemy threat in future 
exercises. 

• It expanded the use of sophisticated news reporting simulation through the use of the 
Virtual News Network (VNN). 

As a result, T2 provided an unmatched opportunity to examine domestic incident management 
policies, procedures, and systems, as well as an oj^rtunity to review critical communication 
and coordination issues as they have evolved since TOPOFF 2000, the terrorist attacks of 9/1 1, 
and the anthrax attacks during the fall of 2001, Therefore, the results and findings of this 
exercise will allow agencies and organizations at all levels of government to identify problems 
and develop solutions. At the AAC, DHS Secretary Tom Ridge underscored the success of the 
T2 model as “a proven framework for bringing together all elements of DHS” and designated the 
TOPOFF Exercise Series as the lead exercise within DHS. 

I). Overview of the AAR 

This After Action Report (AAR) fMX)vides the results of the FSE analysis, and integrates the 
findings from pre-FSE seminars and the LSG.’ The Background .section provides a history of the 
exercise scenario and a brief description of findings from TOPOFF 2000, other exercises, and 
real-world events that have influenced both the design and evaluation of T2. It also outlines the 
exercise evaluation methodology, focusing in particular on how the events of the FSE were 
reconstructed and analyzed. The Reconstruction section summarizes exercise events in the 
Washington and fllinois venues as well as interagency play in Washington, D.C.^ The next 
section details exercise Artificialities. The Special Topics section examines a set of events or 
issues (such as the elevation of the HSAS to Red) that have special significance to the response 
community and which fall outside of or have substantial overlap between the six, pre-determined 
areas of analysis. The Analysis of the Six Core Areas discusses the overarching issue areas 
identified from a review of TOPOFF 2000 and other exercise findings, FSL agency objectives 
for T2 submitted prior to the FSE, and real-world events such as 9/1 1 . Included in this section is 


^ Sixty-four hospitals actively responded to the notional bioterrorism attack in the Illinois venue and 16 hospitals 
responded to the radiological event in the Washington venue. 

' The findings from the seminars, the large scale game, and the ADLE were published previously. 

■* A searchable, detailed reconstruction of events from the WA. IL, and Interagency venues is provided in Annex A. 


3 



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T2 


a summary of how the findings from the seminars and the LSG relate to the conclusions drawn 
from the analysis of the data collected during the FSE. The next section provides A Comparison 
of T2 to TOPOFF 2000. Lessons learned from the design and conduct of the exercise are 
described Exercise Design and Conduct Lessons Learned. In the final section of this report are 
the Conclusions drawn from the Special Topics and Analysis of the Six Core Areas. 

During the FSE, DHS and DOS invited representatives from the Stanford University Center for 
International Security and Cooperation Institute for International Studies to observe activities in 
Washington, D.C.; and the Washington Stale and Illinois venues. Their report is included as an 
appendix to Annex B. 

Two other exercises were conducted simultaneously to the T2 FSE: the TOPOFF 2 CyberEx and 
The National Capital Region Functional Exercise (NCRFE). The CyberEx was a functional 
exercise intended to examine, in an operational context, the integration of inter- and intra- 
govemmental actions related to a large-scale cyber-attack synchronized with a terrorist WMD 
attack against a major urban area of the United States. The NCRFE was designed to coincide 
with the FSE to assist the National Capital Region jurisdictions in assessing their preparedness 
and coordination in response to a general attack on the nation and changes to the HSAS Threat 
Condition. The AAR for the CyberEx can be found in Annex C, and the NCRFE AAR in Annex 
D. 

This AAR, along with its annexes, is designed to support the accomplishments of the exercise 
series goals and objectives and to provide an accurate and comprehensive portrait of the exercise 
conditions. The data contained within the main body of this report encompasses the direct 
observations of nearly 800 FSE data collectors, and the evaluation team’s analysis of that 
information, as well as input from official FSL participants. 



4 




blocks . (...) It will feature the partic ipation of key top officials at the Federal, 
State, and local levels. (...) This series of exercise components will also improve 
“crisis resistance ” through opportunities to measure plans, policies and 
procedures required to (to provide an) effective response to a V/MD terrorist 
incident. (...) 

T2 (...) will support the national s/ro/ggy to combat terrorism, and include events 
that assess the Nation's crisis and consequence management capacity. It will 
include the involvement of Federal. State, and local top officials. The lead agency 
for T2 will he the Department of Homeland Security, and the exercise will he 
designed, developed and executed by Department of Homeland Security (DHS), 
Office for Domestic Preparedness (ODP)' . 

T2 supported the National Security Council’s Policy Coordinating Committee on Counter- 
terrorism and National Preparedness Exercise Sub-group requirement for a large-scale, 
counterterrorism exercise commencing in 2002 and finishing in 2003. 

Homeland Security Presidential Directive (HSPD)-5 articulates the federal incident management 
policy that guided the T2 exercise. HSPD-5. in part, states: 

To prevent, prepare for. respond, to, and recover from terrorist attacks, major 
disasters, and other emergencies, the United States Government shall establish a 
single, comprehensive approach to domestic incident management. In these 
efforts, with regard to domestic incidents, the United States Government treats 

^ The T2 effort was initiated under the auspices of the Office of Domestic Preparedness (ODP) formerly part of the 
Department of Justice. ODP was later transferred to DHS when it was established. 


5 




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T2 


crisis management and consequence management as a single, integrated Junction, 
rather than two separate functions. The Secretary of Homeland Security is the 
Principle Federal Official for domestic incident tnanagement. 

B. Overview of Federal, State, and local Agency Objectives for T2 


Participating FSL agencies were asked to submit objectives to T2 planners at the start of the 
exercise design cycle to ensure the exercise design would support participant objectives while 
also addressing national priorities. Agency objectives covered such areas as unified command, 
mutual aid, law enforcement investigation, mortuary services and fatality managementttpublic 
information/education, surveillance, and epidemiology, among numerous others.^ Figure 1 
demonstrates that the FSE design, as documented and executed through the M^ter Scenario 
Events List (MSEL), largely addressed FSL agency objectives. These objectives wer^linked to 
MSEL items (defined by participating agencies and described, in tbc.^ T2 Exercise Plan 
(EXPLAN)), Those objectives for which the associated MSEL item took place during the FSE 
are noted in the figure as being “addressed at least once,” during.FSE-rplay. Those for which the 
associated MSEL item did not take place are noted as “possibly notfaddressed” during FSE play.’ 




V 


* A detailed list of these objectives is provided as an appendix to the T2 Exercise Plan (EXPLAN). 

^ The word “possibly” is used because just because the associated MSEL item did not occur does not necessarily 
mean the objective was not addressed. Each agency has determined whether its objectives were accomplished and 
has documented this in their respective AARs. 


6 



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T2 


Meeting objectives in the MSELs 

E9 Objectives addressed at least once b O bjectives possibly not addressed 




Venue for objective 

Figure 1. FSE Addressed FSL Objectives 
C. TOPOFF 20(10 

Like T2, TOPOFF 2000 involved sfnujlated terrorist attacks against two metropolitan regions: a 
chemical attack in Portsmouth. New Hampshire, and an intentional release of pneumonic plague 
in Denver, Colorado. Executed during May 2000, the TOPOFF 2000 FSE pre-dated the terrorist 
attacks of 9/1 1 . 

There Were eight principle observations drawn from TOTOFF 2000:* 

• Multiple direction and control nodes, numerous liaisons, and an increasing number of 
response teams complicated coordination, communications, and unity of effort; 

• Threat information and a common “threat picture" were not shared or coordinated in a 
timely manner; 

• Collaboration and methodologies in coordinating and sharing WMD hazard information 
and analysis need to be strengthened; 

• Educating, exercising, and equipping cri,sis and consequence managers and responders 
remained a national priority need; 

** TOPOFF 2000 Exercise Obser\ation Report, page EX- 17. 


7 



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T2 


• The response to a large-scale bioterrorism incident was significantly different from 
response to other WMD; 

• The fragility of the public health infrastructure, reluctance to invest heavily in preparing 
for a low probability event, and shortfalls in current bioterrorism preparedness increased 
the reliance on leadership, effective response, and information management at the federal 
level; 

• The respective and compassionate management of contaminated human remains, 
including legal requirements, evidentiary controls, and evidence collection, and ttieir 
ultimate disposition required concerted analysis and planning; and 

• The importance of joint public affairs in a WMD incident could not be overstated. The 
interagency public affairs community needed to continue to demonstrate an increasing 
capacity for joint public affairs following a WMD incident. 

The success of TOPOFF 2000 was instrumental in obtaining continued funding for conduct of 
subsequent TOPOFF exercises. While the intent was to conduct a no-notice exercise. Congress 
realized the value of a building-block approach to preparedness and instructed TOPOFF planners 
to develop a series of exercise activities of increasing complexity. Many elements developed in 
TOPOFF 2000, such as the Virtual News Network (VNN), were retained and expanded for T2. 
TOPOFF 2000 participants initiated numerous corrective actions based upon the lessons of the 
exercise, and these were evident in the management of the events surrounding 9/11 and the 
anthrax attacks, as well as during the T2 FSE. 

D. Related Real-World Events 

1. 9/11 

The events of 9/1 1 affected T2 planning, which was in the preliminary stages when the attacks 
occurred. In the aftermath of 9/1 1, the President created the Office of Homeland Security, and 
the Administration and Congress subsequently established DHS. Though planning for T2 was 
well underway by the time DHS was established, the participation of the new department became 
imperative, as many of the exercises’ objectives centered around determining how existing 
procedures would be changed by a DHS-managed, federal response to incidents involving 
WMD. 

2. Anthrax 

The attacks of 9/11 were followed by mail-based anthrax attacks. These attacks served to 
underscore and reinforce some of the TOPOFF 2000 observations listed above in the 
Background as well as the need to exercise the nation's bioterrorism response. 

3. Other real-world events 

In June 2002, Attorney General John Ashcroft announced that Jose Padilla, also known as 
Abdullah al Muhaji, had been arrested in May, at Chicago’s O’Hare International Airport, on 
suspicion of both association with the terrorist organization Al Qaeda and plotting with Al Qaeda 
to detonate a radiological dispersal device (RDD) somewhere within the United States. 


8 



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T2 


In early 2003, the Department of Health and Human Services (HHS) began a nationwide 
program to administer smallpox vaccinations to healthcare workers. 

E. The T2 Building-Block Events 

It is important to understand that the T2 design involved a conscious decision to provide 
participants full access to the exercise scenario. This choice was made so that the scenario could 
be used in the T2 building-block events preceding the FSE and also to emphasize the learning 
process of T2.^ 

The building-block events began with the first T2 seminar. Public Communications during a 
WMD Incident, which was conducted in McLean, Virginia, from July 17 to 18, 2002. The 
seminar focused on both the issues that affect a government’s abilities to communicate 
effectively with the public either directly or through the media, and also on the decisions that 
must be made to ensure that appropriate messages are delivered in a coordinated and timely way. 

The second seminar, National Seminar on Bioterrorism, was held in Northbrook, Illinois, from 
September 17 to 18, 2002. This seminar brought together homeland security functional area 
leaders from FSL departments and agencies, as well as the Chadian government, to discuss 
issues involved in response to an unprecedented contagious bioterrorism attack. 

A third seminar. National Seminar on Radiological Dispersal Device Terrorism, was held in 
Seattle, Washington, from October 16 to 17, 2002. The seminar was designed to both identify 
critical issues facing FSL, private sector, and international officials and also resolve key issues 
faced in such an attack prior to the FSE. The seminar explored how FSL and international 
responders prepare for the unique problems created by an RDD scenario and the best approaches 
to resolve these issues. The participants were ^m U.S. Federal departments, Canadian 
agencies, and State and local emergency response agencies from Illinois and Washington. 

The National Direction and Control Seminar was conducted in conjunction with the Advanced 
Distance Learning Exercise (ADLE), which employed distance education technology to 
disseminate information and provide interactive training opportunities. Overall, the seminar 
provided an interactive forum for discussing the nation’s capacity to direct and control crisis and 
consequence management of complex terrorist events. ADLE viewers were given the 
opportunity to pose questions to seminar panel members through the DHS, Office for Domestic 
Preparedness’ Extranet Secure Portal (ESP) website. 

The T2 Large-Scale Game (LSG) was developed to improve the nation’s ability to manage the 
long-term consequences of a terrorism attack. It focused on the mid- to long-term issues that 
challenge FSL and international top officials and responders in the unprecedented event of a dual 
radiological and contagious bioterrorism attack. Participants included senior officials from U.S. 
FSL departments and agencies, as well as representatives from the Canadian Government. 

The lessons learned from these seminars can be found in the after action reports posted on ODP’s 
Extranet Secure Portal (ESP). 

The Top Officials Seminar brought together Cabinet-level officials from 25 agencies and 
departments in a round-table discussion that served as preparation for the T2 FSE through an 


While the scenario was widely known, the Ma.sier Scenario Event List (MSEL) which actually drove exercise play, 
was closely held and not provided to participants. 


9 



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T2 


exploration of inter-governmental domestic incident management in response to WMD terrorist 
attacks on the United States. 

The T2 FSE was played out from May 12 to May 16, 2003. The information contained within 
this document reconstructs and analyzes the FSE and provides recommendations for refining 
future operations of integrated domestic incident management. 

F. Exercise Scenario 

The T2 exercise scenario depicted the fictitious, foreign terrorist organization GLODO''^ 
detonating an RDD in Seattle and releasing the Pneumonic Plague in several Chicago 
metropolitan area locations. There were also significant pre-exercise intelligence play, a cyber- 
attack, and credible threats against other locations. Key events in the exercise scenario are 
briefly described Table 1. 

The Homeland Security Advisory System (HSAS) national threat level was notionally raised 
from Yellow to Orange before the FSE on D-6 in response to credible intelligence reporting 
suspected threat activities. 

The scenario was designed to demonstrate the tiered approach to a WMD respon.se: 

(1) Local first responder capabilities, 

(2) State emergency management capabilities, 

(3) State National Guard capabilities, 

(4) Lead Federal Agency response, and 

(5) Title 10 military support. 

In the RDD scenario, the explosion took place in the Seattle, Washington, and the city was the 
first to respond. Seattle then called in state resources, followed by federal resources where 
necessary. It was not designed to require usage of Title X resources, but nonetheless 
demonstrated the value of the tiered response. 

On D-2 in the Chicago metropolitan area, the plague agent was notionally released at three 
separate locations: 1) O’Hare International Airport. 2) Union Station, and 3) the United Center. 
Multiple people were infected at each site. Some of the plague victims watching a Chicago 
Blackhawk.s versus Vancouver Canucks hockey game at the United Center subsequently traveled 
to Canada. 

On D-Day, the start of the FSE (STARTEX), the RDD was detonated in Seattle, killing a small 
number of individuals, injuring a larger number, and scattering radioactive materials around the 
bomb site and over a broad area as the material was transported by the wind. 

On D+l, the number of admissions to Chicago metropolitan area hospitals made it clear that a 
major disease outbreak had begun both in the United States and in Canada (most notably in 
Vancouver, home of the Vancouver Canucks hockey team). By the end of D+l a clinical 
diagnosis of Pneumonic Plague was made. 

On D+2. with positive laboratory identification of the plague, counties in the Chicago 
metropolitan area mobilized their own pharmaceutical stockpile resources for distribution to the 


10 


The acronym for the fictional Group for the Liberation of Orangeland and the Destruction of Others. 


10 



T2AAR 


T2 


local first responder community personnel. Subsequently, the Strategic National Stockpile 
(SNS) was mobilized, arriving in Chicago at the reception site at O’Hare International Airport. 

On D+3, the SNS was deployed from O’Hare International Airport to five distribution sites 
within the Chicago metropolitan area. 

Table 1. Overview of Scenario 


Exercise 

Day 

Washington Venue 

Illinois Venue 

D-6 

• Increase in hostile cyber-activity 

• Threat condition elevated from vellow to oranec 

D-5 

• Cyber-attacks by GLODO sympathizers 

D-4 



D-3 

• Credible threat against 

Columbia Generatins station 


D-2 


• Coven release of biologicd agent in ttie Chicago 
mclrt)poliian area 

D-1 



D-Day 

• Truck bomb explosion in Seattle 

• Radioactive material confirmed 

• Terrorist Radiological 

Dispersion Device event 
declared 

• Initial patient presentation 

D+l 

• Safehouse takedown" 

• Recognition of patient increase 

• Clinical diagnosis of plague 

• SNS request 

• Nmional Disaster Medical System activated 

• Eoidemioloeical investication underway 

D+2 

• Marine takedown 1 1 

• Command Post Exercise 

• Lab confirmation 

• Establish Joint Information Center (JIC)/Joint Operations 
Center (JOC) and Regional Operations Center (ROC) 

• SNS breakdown 

• Illinois WMD Team Takedown 1 1 

• Overwhelmina #s patients 

D+3> . 

A'- 

. • T^etop Exercise 
• (Ctnisequence Management) 

• SNS distribution begins 

• Midway Airport event 1 1 

• Takedown in Chicago!! 

• Overwhelmina #s patients 

J D+4 

• Hoiwash 

• Hotwash 


' ' These events were walled from the evaluation team, and therefore are not discussed in much detail in this AAR. 


11 













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G. Evaluation Methodology 

This section provides an overview of the T2 FSE evaluation methodology.'^ The process by 
which the exercise was reconstructed and analyzed is given special attention. The T2 evaluation 
goals were to 1) help agencies understand domestic incident management and WMD-related 
issues and develop solutions, and 2) support the establishment of a model for continuous 
learning. 

These goals are consistent with the T2 national goals and those of the T2 domestic venues. As 
such, the evaluation methodology focused on decision and coordination processes that support 
the nation's top officials and the broader system of FSL agencies. Rather than evaluating 
participant ability and performance or specific agency-by-agency objective, the evaluation 
methodology employed a detail-oriented data collection effort to reconstruct T2 exercise events 
followed by an analysis focusing on six pre-selected areas of analysis: 

1. Emergency Public Policy and Decision-making encompasses the unique challenges, 
difficulties, and nuances faced by top officials in the initial aftermath of a terrorist WMD 
attack. These differ from those of natural disasters or accidents and from normal day-to- 
day operations. 

2. Emergency Public Information encompasses the unique public information challenges 
and implications faced by top officials and their support staff in the midst of a terrorist 
attack involving WMD, which may ditfer from that of normal day-to-day operations. 

3. Communications, Coordination, and Connectivity encompasses the challenges of 
exchanging information across all levels of government, information flows supporting 
decision-makers, and the electronic means by which information is exchanged. 

4. Jurisdiction encompasses the issues, conflicts, or gaps in authorities and the assumptions 
that may arise when policies and agreements are put into practice under the uniquely 
challenging conditions of a terrorist attack involving WMD. 

5. Resource Allocation encompasses the issues involving the allocation of scarce 
resources, as well as the management of resources committed during the response to a 
terrorist attack involving WMD.. 

6. Anticipating the Enemy encompasses the unique considerations that influence decision- 
making when there is knowledge of a potentially active enemy threat. 

The After Action Report (AAR) also includes the analysis of several special topics. These topics 
represent events that attracted particular interest during the FSE and crossed multiple areas of 
analysis. 

Evaluation of the FSE consisted of a three-step process: 

Step 1: Observation and data collection during the exercise. 

Step 2: Reconstruction of events and activities. 

Step 3: Analysis of what happened in the exercise and why, in terms of the special topics 
and the six core areas. 


■ A detailed presentation of the methodology can be found in the Exercise T2 Evaluation Plan (EVALPLAN). 


12 



T2AAR 


T2 


This methodology was intentionally structured not to evaluate player performance. Instead, the 
purpose was to deliver knowledge to players so that they, and non-participating agencies 
nationwide, can improve or create FSL policies and procedures based upon the lessons of T2. 

1. Observation and data collection 

T2 involved an aggressive data collection strategy.'^ Hundreds of data collectors and controllers 
in the field collected data. Other data were obtained by collecting the paperwork (e.g., duty logs) 
kept by some players in the course of executing their duties, by having a central point to which 
T2-related e-mails were to be sent, and by asking controllers— especially those in the control 
cells — to turn in their notes. In addition, the T2 evaluation team collected feedback from players 
at all levels of government through the use of player feedback forms. A key element in all this 
data-collection was time: each observation was annotated with a time at which players recorded 
it to have occurred. An unprecedented volume of data was collected during the course of the 
FSE, and was thus a tremendously successful aspect of T2. 

2. Recomstruction 

T2 analysts collected and organized the data submitted by players, data collectors, and 
controllers to use in the reconstruction and analysis of FSE play. Figure 2 illustrates the 
reconstruction process. Analysts reviewed data from play sources (data collected through the 
course of T2 play) and control sources (data collected through T2 controllers) for each venue and 
highlighted data points that could support analysis of what happened and why during the 
exercise. Play data included logs kept by players during the course of the FSE, player feedback 
forms, e-mails, and data collector logs. Control data, which documented the occurrence of 
MSEL items and ad hoc injects during play, included field controller logs, as well as data 
collected in the Master and Venue Control Cells during the course of the FSE. 

The evaluation team received data from numerous FSL agencies and non-government 
organizations. The.se include; The Center for Disease Control and Prevention, Department of 
Energy, Environmental Protection Agency, Federal Bureau of Investigation, Federal Emergency 
Management Agency. Federal Radiological and Assessment Center, Food & Drug 
Administration. Department of Heath and Human Services, Department of Homeland Security, 
Department of Housing and Urban Development, National Oceanographic and Atmospheric 
Administration, Nuclear Regulatory Commission, Occupational Safety and Health 
Administration. Department of Transportation, U.S. Coast Guard, U.S. Marshals Service, 
Department of Veterans Affairs, State of Illinois Emergency Operations Center (ECXD), Illinois 
Department of Public Health. Illinois Operations Headquarters and Notifications Office, Illinois 
Joint Operations Center, Chicago Metropolitan Area EOCs and Public Health Departments, 
participating Chicago Metropolitan Area hospitals. State of Washington EOC, Washington Stale 
Department of Health, Washington Joint Information Center, Washington Joint Operation 
Center. Seattle and King County EOCs, Public Health Seattle/King County, Seattle Police and 
Fire Departments, participating Seattle and King County hospitals, and the American Red Cross. 

Where applicable, analysts tagged the data collected at the FSE, and from venue Hotwashes, the 
After Action Conference (AAC), agency AARs, and post-FSE interviews with exercise 



Also described in detail in the T2 Evaluation Plan (EVALPLAN). 


13 



T2AAR 


T2 


participants, for instances of potentially good practices'** or challenges in the Six Core Areas of 
Analysis and the Special Topics. The data were then entered into two distinctive databases for 
each venue; one containing the electronic record of play data tagged for the six core areas, the 
special topics, and artificialities; one containing the electronic record of control data (see #2 in 
Figure 2). The play database totaled more than 20, (KX) lines of data for the Washington, Illinois, 
and Interagency venues. The control database equaled the length of the MSEL and ad hoc 
injects, but also documented varying controller inputs on the times events took place. 


T2 Reconstruction Process 


T. Source data was collected 
from the FSE and physically 
organized lor review. 

2. 'Play' data was tagged lor 
areas of analysis and special 
topics, and entered into 
spreadsheet. 'Controller' data 
is assimilated and entered into 


3. Key events and decisions 
were identified in "catirol' and 
“play'data. redundancies 
eliminated, and time conllicts 
reconciled (documenting 
uncertainties and logic where 
judgment was used). A 
reduced set ol play and control 
data on evenls/decisions was 
then integrated for each venue. 


4. Alt venues we integrated 
Into the Master Reconstruction 
lile and lime-synchronized lor 
Eastern Daylight Time (EOT). 

5. Master Reconstruction product 
was distributed and Integrated 
Raw Data archived. 




(2) Venue (WA) 


e- -s 

(2) Venue (WA) 


• 

Play Perspective 


Control (MSEL) Perspective 



Raw Data Mirte 


Raw Data Mine 



(Spreadsheet#!) 


(Spreadsheet #2) 




Figure 2. T2 Reconstruction Process 


The analysts then reviewed the databases for each venue and identified decisions and significant 
events that occurred during the exercise from both the play and control data sets (see #3 in figure 
2). The purpose was to filter out the innumerable events and decisions that participants faced on 
a daily basis, and to identify only those events that triggered top official decisions or actions. 


For each data point identified as a significant event or decision, analysts researched the data to 
create a thorough event or decision description. For example, from one data point that read, 
“Susan approved the release,” analysts were able to deduce from other data points recorded 
during relative time frames that Susan was from the Washington State Emergency Operations 
Center and approved a press release announcing the re-opening of local highways. Using this 


“Good” indicates that the intent ultimately is to objectively validate it as a “best” or “exemplary” practice. 


14 













T2AAR 


T2 


process, analysts created a comprehensive list of significant events and decisions that 
participants experienced during the two scenarios that were played out in the Washington and 
Illinois venues during the FSE. This comprehensive listing of significant events and decisions 
was then transferred to a new worksheet, which became the foundation for the reconstructed 
timeline for each specific venue. 

As part of this research, analysts reviewed the various times that were noted in all the data 
gathered from players, controllers, and data collectors for each given event or decision and then 
reconciled differences. In some cases, participant records indicating when events or decisions 
occurred varied by hours. The analysts used their judgment to determine the most reasonable 
time to assign to an event when data was not available. For example, if eighty percent of people 
recorded an event occurring at 0900 CDT then the analysts went with the time reflected by that 
eighty percent and only noted the outlying times. Likewise, if accounts of when an event 
occurred were equally distributed with no indication of an authorit^ve time, the analyst 
determined the average of the times. Despite widely varying accounts of when an event 
occurred, in some cases — such as the time of the RDD explosion in Seattle — the actual time is 
known because it was controlled; therefore, the actual time is entered and its basis documented. 
The specific times for events or decisions are less important in the overall reconstruction effort 
than the overall sequence and flow of events. The purpose of the reconstruction is to provide an 
objective context for the analysis and to provide a resource to FSL agencies that describes the 
types of events or decisions agencies could expect to face in real-world responses to the types of 
terrorist WMD attacks depicted in T2. 

Once the event/decision descriptions were complete and the times were reconciled for each 
venue, the reconstructed timelines for each venue were combined into one master reconstruction 
file and sorted by date and time to produce a fact-based, integrated, reconciled, objective, 
meaningful timeline of events for the FSE. This timeline is the basis for the analysis presented in 
the AAR, and is the timeline provided as Ajtne.x A. 

3. Analysis 

The analysis process is depicted.in Figure 3. Analysts consulted the play and control databases, 
as well as inputs from participants obtained through the player feedback forms, the Hotwashes, 
the AAC, and Lessons Learned reports submitted by agencies during the analysis process. The 
AAC was designed to allow pwuticipants and planners to provide additional input to the analysis 
process. For each special topic (described in more detail below), analysts consulted the collected 
data to create a more detailed reconstruction of events and decisions occurring within that topic’s 
frame of reference. Analysts identified and analyzed the artificialities that impacted play in these 
topic areas, weaving the varied, distributed, and complex pieces of each dynamic response into a 
single unified story. In many cases analysts followed up with participants through phone calls 
and emails to clarify the data collected during events, decisions, and artificialities. To lay a 
foundation for development of objective qualitative and quantitative measures in the future as 
well as iessons-leamed and best practices, the analysts identified instances of good practices or 
challenges in the six core areas in each special topic, reviewed additional instances that were not 
tied to special topics, and identified findings across the exercise 


15 



T2AAR 


T2 


T2 Analysis Process 


1. Source data ware 
collected from the 
FSB and physically 
organiied lor review. 

2, 'Play' data were lagged » 
for areas of analysis and i' 
Special topics, and entered into 
spreadsheet. 'Controller" data 
were assimilated and entered into 
spreadsheet. 



FOR BACH STORY. 

3. Analysis reconstructed story 
and identified 'instances' in 
the core areas of analysis. 




(2) Venue (WA) Pley 


Per>peciiv« 

: s ^ 

Raw Data Mina 

9 

~ iRoreadsheal «1 1 

■ 


(6) Review of 
T2000 and 
Seminars 


(3) Identification 
of 'Instances' 


Venue (WA) 

Control (MSEL) Pertpeelive 
Date Mine 
(Spreadsneel «2) 


Foreaehstory] 


(3) Building of 
Story 
Timelines 




S'. 

•( 


4, Analysis drafted summaries of the 
stories. artiUdalllies impacting on 
stories. andfincSngs 

THEH 

6. Anaiysts reviewed tagged data 
and stories, and drafted summaries of 
the core areas of analysis across 
the exercise spectrum. 


6. In parallel, analysts 
conducted comparative analyse 
of Ouildingbloclts across 
T2 and TOPOFF series 


’ (5) Draft summane^ 
of core area 
findings aaoss 
exercise 


* (4) Draft analysis of 
findings for stories 
' Develop analytic 

nnvltirle 



Figure 3. T2 Analysis Process 


'-a 


'e 

% 

\ 


16 


T2AAR 


T2 


III, RECONSTRUCTION OF THE FSE 


The purpose of the reconstruction was to establish an objective, fact-based timeline of the events 
that unfolded during the Full-Scale Exercise (FSE) as the foundation and context for analysis. 
The complete Top Officials (TOPOFF) 2 (T2) reconstruction product is the result of reviewing 
approximately 400 data collector and controller logs; thousands of player feedback forms and 
participant logs; many CD-ROMs; more than 2.500 emails; and hundreds of Master Scenario 
Events List (MSEL) items. These data sources were compiled into a spreadsheet amounting 
approximately 20,000 lines of data. The spreadsheet was then sorted by time, taking account 
each venue’s specific time zone, and decisions and events were identified and filtered for 
redundancy. 

This reconstruction, and therefore the rest of this report, does not include certain T2 activities 
that were partially or totally fenced off from both the analysts’ view and from other events in the 
exercise. These include various force-on-force takedown drills; a cyber-attack exercise 
(CyberEx), the After Action Report (AAR) from which is published in Annex C; and some 
branch or sequel activities taking place wholly inside Canada and the National Capital Region. 
Furthermore, this report does not include significant data on international or Canadian play, 
which were collected and analyzed by the Department of State (DOS) evaluation team, the 
results of which are published in Annex B. 

The activities described in this reconstruction took place in three different time zones. To 
report all in terms of their Eastern Daylight Time (EDT) equivalents would force readers with a 
Washington or Illinois perspective to adjust their venue’s institutional memory or records with 
EDT; it might also distort the connotations borne by certain times (e.g., those participating in the 
very early hours, and those that come at the end or beginning of the workday, or at a shift 
change). Yet the goal is to create a unified timeline of events. Accordingly, events are presented 
in the order in which they happened, but narrated in terms of the local times applicable in each 
venue. 

Events that transcended particular time zones, such as Virtual News Network (VNN) broadcasts 
that were seen everywhere simultaneously, are given EDT times. 

It is important to distinguish between events that were physically executed in the exercise and 
those that were done notionally. The physical activities involved: 

• Participating top officials, and those top officials who were represented by somebody 
else; 

• Participating agencies’ personnel, numbering in the thousands; 

• The more than one hundred “injured” persons in Seattle, represented by role players, and 
augmented by a few mannequins; 


Seattle is in the Pacific time zone; Chicago in the Central time zone, and the Washington, DC-based Interagency 
venue is in the Eastern lime zone. 


17 




T2AAR 


T2 


• The hundreds of role players acting the parts of the Chicago Metropolitan area patients, 
augmented by paper patients; and 

• VNN broadcasts. 

While these parties’ actions were affected to some degree by exercise artificialities, they were 
real in the exercise sense that somebody physically participated and performed an action or 
actions, thereby encountering some semblance of realistic time delays, possibility of errors, and 
the issues that real operations entail. 

All else — the closures of highways, airports, and ferry systems; orders to the population to 
shelter-in-place, elevations of the Homeland Security Advisory System (HSAS) TTireat 
Condition; the spread of Pneumonic Plague outside the Chicago metropolitan area; etc. — was 
done in a purely notional sense. Also, all requests for emergency powers, changes of alert status, 
and so on were granted only on an exercise basis. 

What follows is a reconstruction summary in a tabular format to lend context to the analysis. 
The table format affords the reader with the ability to view the events of one venue against the 
context of the others. Specific times are indicated based upon the data. They are provided not 
for the purpose of pinning events or decisions down to the exact minute, since the vast volume of 
data and multiple observer/participant accounts do not allow for such precision, but rather to 
illustrate the overall sequence of key events and decisions. Acronyms are not spelled out in the 
table for abbreviated readability, but all may be found in the Acronym Guide provided as a 
glossary to this AAR. 

A complete, searchable reconstruction product is provided in Annex A to this AAR. It enables 
agencies or other interested readers to understand exactly what happened in T2, and more 
importantly — what types of activities and decisions one could expect to encounter in a 
radiological dispersal device (ROD) or bioterrorism attack from various perspectives and all 
government levels. • 



18 



T2AAR 


T2 


Table 2. T2 Summary Reconstruction 


D-Day, Monday, May 12 


Time 

Washington i 

Illinois 

Interagency and Foreign 

1200-1300 

PDT 

1400-1500 

CDT 

1500-1600 

EDT 

Bomb blast in Seattle. Seattle 

EOC activates to Level III. 
Washington EOC activates and 
notifies FEMA Region X ROC. 
Seattle HAZMAT, responding 
to blast, detects radiation. FBI 
JOC stands-up and 
investigation imitated. 

Illinois EOC activates 

Chicago EOC activates 

HHS receives message traffic 
from DHS, reporting the 
presence of Pu 229, Ce 137, and 
other radioactive materials in 
the bomb.'* HHS reacts by 
officially activating the Region 

X REOC and sending the SERT 
there. SNS Operation Center 
activated. 

1300-1400 

PDT 

1500-1600 

CDT 

1600-1700 

EDT 

Air, rail, highway, and ferry 
closures in Seattle area. Seattle 
and King County announce Red 
Alert status. Discussions of 
plume modeling and shelter-in- | 
place begin. Washington 
requests DOE RAP assistance i 

Chicago increases security at 
likely terror targets. 

DBST deployed (actoally. 
redirected) to Seattle. 

Rumors of National. National Capital Region, and Chicago transitions to HSAS level Red abound. 

1400-1600 

PDT 

1600-1800 

CDT 

1700-1900 

EDT 

Seattle implements shelter-in- 1 
place, declares State of 
Emergency. Governor declares 
State of Emergency, activates 
National Guard. FRMAC 
requested. Second bomb 
identified on-site. FBI HMRU ^ 
arrives on-site 

Lake County EOC activates. | 
Hospitals alter command 
rclatiCHiships. Governor 
increases security at nuclear 
power plants. DuPage County 
EOC begins 24-bour staffing. 

DOE sends Prussian Blue to 
Seattle. 

Deputies meet 1700; Principles 
meet 17.30. 

1600-1700 

PDT 

1800-1900 

CDT 

1900-2000 

EDT 

Stafford Act 40 1 request by 
Governor of Washington for 
Declaration of Ms}or Disaster. 
Shelter-in-place declared 

RDD info faxed to hospitals by 
Chicago Department of Public 
Health. Public transit stepped 
up. Four SARS-like patients 
coughing up blood arrive at 
Edward Hospital in DuPage 
Countv. 


1700-2100 

PDT 

1900-2300 

CDT 

2000-2400 

EDT 

Port to Marsec 3 per USCG. 
DEvST and PFO arrive. AMS 
conducts survey. FRMAC 
arrives i 



DHS Secretary declares HSAS Red for Seattle, Los Angeles, San Francisco. Houston, Chicago. New 
York, and Washincton. D.C. 


Knowledge of Pu 229 as part of the RDD this early in the exercise is an artificiality. It was not definitively 
identified by radiological experts in Washington State until late on May 12, 2003. 


19 







T2AAR 


T2 


Morning of D+l, Tuesday, May 13 


Time 

Washington 

Illinois 

Interagency and Foreign 

2100-2400 

PDT 

2300-0200 

CDT 

0000-0300 

EDT 

Formulation of plans to 
evacuate workers and 
businesses west of 1-5 from 
shelter-in-place and re-opien 
highways. Rubble pile declared 
clear. Transition RDD site 
from rescue site to crime scene. 

First Pneumonic Plague case 
suspected. 


0000-0300 

PDT 

0200-0500 

CDT 

0300-0600 

EDT 


More apparent cases of 
pneumonic plague. 

CDC EIS team on-scene. 

British Columbia C^^^onfirms 
Pneumonic Plague. 

0300-0500 

PDT 

0500-0700 

CDT 

0600-0800 

EDT 

Debate over 1-5 re-opening. 
Evacuation of workers and 
businesses west of 1-5 begins. 
Ferries resume service except 
to Seattle. 

SERT to increase disease 
surveillance. 

y 


0500-0700 

PDT 

0700-0900 

CDT 

0800-1000 

EDT 

Recovery and Restoration Task 
Force appointed. Presidential 
Declaration of Major Disaster 
approved. 


\ 

i 

call with Region V (Chicago) to discuss 
biological event. 

0700-0800 

PDT 

0900-1000 

CDT 

1000-1100 

EDT 

State disagrees with Mayor oitsg 
opening 1-5. T 

Illinois PeptT^mtiblic health 
^^fifi&rence call m clinical 
oicfOT»|dMea.se. Hospitals 
to see connection to 
lUnited Center. O'Hare 
lupmational Airport. Union 
STation. and Canada. VNN 
reports flu-like illnesses in 
Vancouver. 

DOS stands up liaison with 

Canada. Border security 
heightened - decontamination 
concern. Canadians intercepting 
Seattle flights for possible 
decontamination, 



llsc rumors of National transition to Red Alert status abound. 


announce embargo on 
foodstuffs. 

Ameriilum ^1. plutonium 
238, an^ ce^m 137 confirmed 
in RDE&^^blems with plume, 
road reopening, and 
ijv^uation of those sheltering- 
place. 


Chicago Public Health 
proposes to identify travel 
history of all Pneumonic 

Plague patients. JIC press 
release announces plague 
confirmation. 

CDC Director warns against over- 
commitment to Seattle and 

Chicago. EST Level 1 activation 

SNS readied for release to Chicago area. 

United Center-Blackhawks- 
Vancouver connection 
deduced. 



0900 

PDT 

1100 

CDT 

1200 

EDT 


Authorities strive to get accurate counts of victims. 


Secretary of DHS gives threat update to nation via VNN, confirms terrorist attack in Seattle. 


20 








T2AAR 


T2 


Afternoon of D+l, Tuesday. May 13 


Time 

Washington 

Illinois 

Interagency and Foreign 

1000-1100 

PDT 

1200-1300 

CDT 

1300-1400 

EDT 

FBI investigalion of crime 
continues. 

FRMAC beginning to develop 
long-tenn assessment and 
monitoring plan with EPA and 

HHS. 

Disagreements over need for. and 
utility of, Prussian Blue in 
combating radiation. 

Environmental samples taken at 
O'Hare. Union Station, and United 
Center. IDPH Lab confirms plague 
bacterium samples from patient. 
Governor declares State of 
Emergency and requests activation 
oftheSNS. IDPH declares Phase 

II Public Health Emergency to 
ensure authorization of certain 
emergency procedures Emergency. 
Lake Countv declares disaster. 

State Department standing up JTF w/ 

CAN to work border and flight issues. 

Need to inform receiving countries that 
there may be a health problem in 

Chicago. HHS ASPHEP suggests plague 
was intentionally released, and suggests a 
look at the ventilatortiiuation. 

VNN has DHS Secretary in telephone interview. He announces preliminary diagnosis bf fliMike symptoms as 
"plague.” 

VNN asks him what people in Code Red cities should do. Secretary articulates "sntwdav" concept. 

1100-1200 

PDT 

1300-1400 

CDT 

1400-1500 

EDT 

Teams of specialists search rubble. 

Governor advised to request a | 

National Medical Disaster Syston 
to get Federal assistance; raobilizM 
lEMA. Pon of Chicago closed. j 


1200-1400 

PDT 

1400-1600 

CDT 

1500-1700 

EDT 

Agricultural precautions 
announced. Detailed plan 
developed for shelter-in-place zone: 
those east of 1-5 arc relca.sed: those 
remaining west of 1-5 to be 
evacuated. ^ 

Chicago andCopk County sign 
joint E)acTaratioiief Emergency.. 

CDC confirms plague. All NDMS 
response teams been activated for 
possible deployment. DHS Secretary 
recommends lifting transportation 
restrictions on airports and ferries in WA; 
HHS. DOE, EPA acree. 

1300-1500 

PDT 

1600-1700 

CDT 

1700-1800 

EDT 

1 

(mere Intemaiienal Airport 
closed feSB^ to receive SNS). No 
sdtool in Giicago. 

HHS Secretary declares a public health 
emergency in the City of Chicago, 
allowing the department to provide 

Federal health assistance under its own 

auihoritv. 

In prcsH conlb<aK& DHS Secretary announces HSAS Red for entire Nation: plague in Illinois 

1500-1600 

PDT 

1700-1800 

CDT 

1800-1900 

EDT 

Shcltcr-in-place zone^raddally 
being downsized. 

1 

Governor of Illinois sends letter to 
the President through FEMA 

Region V Regional Director 
requesting Major Disaster 
Declaration. All water, air. bus, 
rail, interstate traffic curtailed. 


16005200 

itJT 

1800-2400- 

CDT 

1900-0100 

EDT 

King Cixinty announces 
implemdMitlon of snow-day like 
regime without specincally 
j identifying or using the term "snow 
diiy." 1-90 is open; 1-5 open to 
' throueh traffic. 

FBI investigation initiated.. 

DHS/EPR/FEMA Headquarters 
recommends to DHS Secretary and the 
President that an Emergency Declaration 
be made in Illinois rather than a Major 
Disaster Declaration. 


21 








T2AAR 


Morning and 
Time 
2200-0600 
PDT 

0000-0800 

CDT 

0100-0900 

EDT 


0600-0800 

PDT 

0800-1000 

CDT 

0900-1100 

EDT 


Washington 

Illlnois 


Steep rise in respiratory cases 
showing up at hospitals. 

Question arises as to whether 
pending local declarations are 
necessary given the IL Governor’s 
declaration of a Stale of 

Emerecnev. 


DHS Secreta 


0800-0900 

SeaTac, King County, Renton, and 

PDT 

Paine Field airports re-opened with 

1000-1100 

restrictions. 

CDT 


1 1(H)- I2(K) 

EDT 



goes on VN N and confirms the disease outbreak as | 
IDPH director authorizes 
distribution of drugs to first 
responders. National Disaster 
Medical System (NDMS) 
requested. Governor recommends 
that non-essential workers stay t 

home and that public gatherings be ' 
cancelled. Counties declare \ 
emergency and “snow day\ 

Plague's origin at O'Harc. Uuim ^ 
Station, and United Center J 

confirmed. DuPage County be^f 
distributiou^^ pharmaceutical \ 
stockpil^o finksDonders 


Interagency and Foreign 
FEMA conference call with 
Regions to discuss numerous State 
inquiries regarding SNS push 
packages. TSA/FRA/STB conflict 
over authority to shut down rail 
traffic. 

>lague, with a terroris^^tan. 





Is HIPPA. Blood 


A|g||idspilal] 
id confidentiality 
^^S lands at 



0900-1000 

City confronts problem of 

PDT 

contaminated fire^gines and 

1100-1200 

police cars. 

CDT 

1200-1300 

v> 


1000-1200 I l^£G/FBl takedown ol^^orisls. | Presidential C 
PDT i^lffl^n-placc zone no, 

1200-1400 V evacuAd. re-named “exclusionary about level of 
CDT zone," iaasmu^ as it has been antibiotic supi 

13QB^OO fully eviu^^ AMTRAK ofEmergency 

announcMRntamination of requests Nalic 

passengCT rail cars. USCG lifts no- counties and < 

^^ai^order. Misgivings and receive and bi 

^%umenls over exclusionary zone; shipments. A 

some want to expand it, others to closed. Many 

end it. Little radiation data. beds and/or ai 

Agricultural control areas and against crowd 

check-points established. 

Casually estimates developed. 


ORT amvc at Hines VA 

t pital. Eighteen hospitals at 
tmum capacity. Persons who 
Jf?ve been at one of three epicenters 
advised to gel prophylaxis. FBI 
JOC opens. 


Presidential Declaration of 
Emergency approved. Concern 
about level of demand relative to 
antibiotic supply. Chicago Office 
ofEmergency Management 
requests National Guard. Area 
counties and Chicago begin to 
receive and break down SNS 
shipments. Area Stale parks 
closed. Many hospitals have no 
beds and/or ate locked down 
against crowds. 


Canada says that they have 
quarantined all those on flight from 
Chicago that brought plague to 
Vancouver. 


22 




T2AAR 

rUK U 

FFICIAL USE ONLY 

T2 

Evening of D+2, Wednesday, May 14 

Time 

Washington 

Illinois 

Interagency and Foreign 

1400-1700 

PDT 

1600-1900 

CDT 

1700-2000 

EDT 

New radiological readings indicate 
that DOH may recommend re- 
closing 1-5 and 1-90. National 

Guard activates 500 troops to 
support law enforcement. 

25 reftigeraled trucks called up lo 
be used as morgues. Counties 
begin prophylaxis of first 
responders. 


1700-2100 

PDT 

1900-2300 

CDT 

2000-2400 

EDT 


Some counties close dispensing 
down for the night. VMI begins 
arriving in-State. 


D+3, Thursday, Mav 15 


Time 

Washington 

Illinois 

Interagency and Foreign 

2100-0500 

PDT 

2300-0800 

CDT 

00(X)-09(K) 

EDT 

Transportation restrictions lifted 
except in vicinity of nuclear plant. 

Public activities curtailed until s , 
least 1800 PDT. \ 

Interstate transportation s 

closed. ' 

FBI takedown of terrorists antj*^ 
terrorist 1 ih . \. 

cod&inating officers 
de^Sjy^ lojeattle and Chicago, 
^frtcreased security on incoming 
'containers. 

\ 

0500- 

ENDEX PDT 

0800- 

ENDEX CDT 

0900- 

ENDEX EDT 

Transition back toHSA5rf!iSan.e)L 

Ail SI^ distnSSion sites open lo 
thepofalic. Mixed messages as 10 
who shotddweVfreataim. 

Plague bacMdik reported still 
present at the (tnw nispecied 
nteOK sites. Mixed messages on 
re-«penii||or the release sites. 
pNon-terrarist-rclated crash at 
Widway. FBI investigation 
Continues to ENDEX. 
cent for Chicaco and New York Citv. 

DOE requests activation of the VA 
Medical Emergency Radiological 
Response Team (MERRT). 




23 




T2AAR 


T2 



24 



T2AAR 


T2 


IV. ARTIFICIALITIES 



Artificialities are manifestations of the exercise’s non-real nature. As such, they are 
unavoidable, and not indications of a problem. However, false conclusions can arise if their 
natures and effects are not appreciated. This section focuses on the key artificialities that need to 
be understood to draw the appropriate conclusions from the Top Officials (TOPOH?i), 2 (T2) 
Full-Scale Exercise (FSE). Exercise artificialities are placed in three broad categories; 

• Those that are inherent to the exercise design process; 

• Those specifically related to the T2 exercise design; and 

• Those that arose during actual exercise play. 

The net impact of artificialities can be difficult to assess. For example, considerations must be 
taken into account for questions such as did a particular artificiality make the response decisions 
or actions easier than they might have been, or did they unnecessarily complicate the response 
relative to a real-world operationl For their part, the T2 exercise designers tried to strike a 
balance, compensating for one artificiality (e.g., a respionse team's need, absent a real 
emergency, to take a commercial flight) with another (e.g., the same team’s seemingly premature 
departure). 

Two questions to ask when considering an exercise artificiality are: 

• What difference did it make to the participants’ play; and 

• What difference did it make to top officials’ play? 

A. Inherent Exercise Design Artificialities 

Artificialities surface in any exocise involving the response to a (WMD event. The fundamental 
issue is that it is often impossible to exercise the full scope of a real-world event — ranging from 
an actual bomb detonation to shutting down transportation infrastructure to commanding the full- 
time attention of top officials. The result is that many exercise events or actions must be 
notional, or simulated, instead of actual. Despite the notional character of some events, 
government agencies and organizations played as though the events actually took place. This 
allowed the T2 evaluation team to examine critical decision-making and communication issues. 
In summary, as long as they are understood and accounted for in the analysis process, these 
limitations need not have a significant impact on interpreting the results of the exercise. 


1. Top officials’ play 


By any standard, top official involvement in T2 was extensive. But in a real-life emergencies of 
the same magnitude of those portrayed in T2 top officials would be immersed in coping with the 
emergency, almost to the exclusion of all other activities, whereas even in T2, top officials were 
present only intermittently and largely on a schedule. In fact, the ability to schedule top official 
play was one of the reasons for pre-scripting some aspects of the exercise. Top officials devoted 
considerable personal time to the exercise. Some also designated individuals (e.g., a deputy) to 


25 




T2AAR 


T2 


play their parts in the game when they were not available. The T2 evaluation team believes that 
top official play during the FSE was, on the whole, relatively unaffected by these artificialities of 
scheduling, availability, and substitution. 

2. Limited scope of play 

Many effects associated with a radiological dispersal device (RDD) explosion and the intentional 
release of Pneumonic Plague were not designed into or played in the exercise. Some of the most 
important include; 

• Transportation gridlock in both Chicago and Seattle; 



Increased security manpower requirements resulting from the attaclSstas well as 
elevation of the Homeland Security Advisory System (HSAS) to Red; a&d 

The potential for population disruption, movement, anxiety, imdfear^^ 

Many of these are nearly impossible to simulate or would have unacceptabl&impacts on non- 
exercise participants. ^ ^ 


3. Notional actions 





Because of limits on the scope of play, the most apparent artificialities were those in which 
notional (or constructive) actions replaced real one»^ Examples include the notional closure of 
1-5 near the Seattle RDD site and the use of paper^patients in the Chicago metropolitan area 
hospitals. 


4. Limited public involvement 

In a real event, the public reaction can include clamor for more information, crowds of people 
who have fled their homes, traffic jams, or disruptive reactions at top officials’ public 
appearances. Although T2 had people to role play patients in the Chicago metropolitan area 
hospitals and persons injured by the blast in Seattle, the general public was minimally 
repre.sented, so reactions on the part of the public simply did not occur. ’ Neither traffic jams 
nor public demonstrations would be feasible, from a practical standpoint. Inasmuch as these 
could have an impact on the top officials’ decision-making, and perhaps even on the actions of 
emergency personnel at the scene, to preclude their existence was to introduce a necessary 
artificiality. 

The Washington venue did have a shelter facility set up at the White Center (a county recreation 
facibty), through which many people passed, and three other shelters (one in Seattle and two in 
King County) were operated on a constructive basis (i.e., no refugee role players), but these 
activities were scripted and did not entail the important aspect of responding to an emerging 
public reaction. 

Many important considerations would include but not be limited to those regarding public 
information, heightened public anxiety, and other psychosocial factors. Such issues would 
expand beyond the immediate affected communities. For example, other cities in America, not 
coping with an on-going emergency, would look for guidance regarding what might later happen 


Public awareness of T2 in Seattle did re.suil in some outcry, such a.s some threatening-looking signs, of which 
nothing ever came. 


26 



T2AAR 


T2 


in their cities. The lack of involvement from 48 non-affected states and hundreds of non-affected 
cities is an artificiality that must be taken into account when considering national top officials 
play. 


B. Artificialities Specific to the T2 Design Process 


The artificialities in this section either represent deliberate choices made during the design of T2 
or are specific to this particular exercise (as opposed to exercises in general). These choices 
were made with the understanding that they would have impacts on exercise findings. The T2 
evaluation team believes that these impacts are accounted for in the exercise analysis. 

1. The known scenario 

T2 was designed as a building-block process whereby the general exercise scenario explored 
in a series of seminars, a large-scale game, and an Advanced Distance Lcarohig Exercise 
(ADLE). This process was designed to promote learning among the agencies ahd organizations 
involved in T2 and, indeed, participants felt that they had learned a great deal even without the 
benefit of the FSE. It is important to note, however, that while the scenaiio was known, 
participants were not afforded access to the Master Scenario Event List CMSEL), which drove 
the FSE play. 

There was some post-exercise criticism in the media about the ov^ly scripted nature of T2 and 
the lack of free play. However, this turns out to be largely unfounded criticism. Figure 4 
compares the times at which events in the MSEL were supposed to occur versus when they 
actually occurred, The figure shows that there was a substantial amount of free play. 

MSEL time offsets by venue 

• Washington <WA) • llinois (R.) • Ritoragency (lA) 


3 

I 


24 
IS 
12 
6 
O 
-6 
-12 
-18 
-24 

1 2-May 2003 1 3-May 2003 1 4-May 2003 1 5-May 2003 1 6-May 2003 1 7-May 2003 

Intended event dale/llme (EOT) 



^ 

Figure 4. Variance of Events from MSEL Times 


1. Scope of participation 

A number of important organizations and governments were simulated. Two notable ones were 
the World Health Organization and the Government of Mexico. 


27 


T2AAR 


T2 


3. VNN 

Prior to the FSE, the Virtual News Network (VNN) staff and director repeatedly made the point 
that during the FSE VNN would be a reporter of the news, not a news-gatherer. But the full 
import of this policy was not clear to many until after the FSE was underway: prior to that time, 
some players appeared to assume that VNN would in some fashion seek out news, as well as 
report it. 

VNN reporting was principally based upon assuming that MSEL events would happen as 
scheduled: reports (many of them included at the bottom-of-the-screen, known within the media 
as “crawlers”) were put on screen straight from the MSEL, without any news-gathering to 
determine whether or not they had actually taken place. This practice resulted in at least one 
instance in which an event was reported before it actually took place.'** Reactions to these events 
may have created some chains of anomalous events, but the effects do not appear to have been 
severe. 

Some VNN coverage (e.g., some top officials’ interviews) was by necessity pre-constructed and 
indicative of the MSEL, and thus did not accurately portray how the scenario was unfolding. 
Again, this style of coverage was completely consistent with VNN's prior self-characterization 
as “a news-reporting, not a news-gathering” organization. 

Finally, the players — particularly those involved with Public Information — did not find 
themselves in a completely realistic media environment of reporters demanding the answers to 
questions. Only in news conferences did any such behavior occur, and even there it was not 
played to the degree of a real-world catastrophic event. 

4. Spread of the Pneumonic Plague 

Two key issues were not played in the T2 exercise: the actual epidemiological investigation 
required to pinpoint the location where individuals were initially infected and the impact of 
counter-measures (prophylaxis, population movement control measures) on the spread of the 
disease. In the former case, while the large number of infected individuals who attended a 
hockey game at United (Tenter would have been a strong clue, the much smaller numbers 
infected at the transportation hubs could have been a greater challenge. In the latter case, the 
exercise ended before the counter-measures could have had their full impact on suppressing the 
transmission of the disease.'^ 

The secondary population in a real epidemic largely consi,sts of people who were in close contact 
with the primary population — family members, co-workers, and health care workers. In the T2 
scenario, the secondary population was constructed on a geographical basis; the numbers of 
secondary cases in the Chicago metropolitan area and in the collar counties were proportional to 
the numbers of primary cases in each of those areas, but the association was no closer and the 
secondary population did not consist of close associates of the primary cases — family members, 
co-workers, health-care workers, and other first responders such as Emergency Medical Services 
workers. 


The RDD explosion itself was one such instance: it was scheduled for 1458 EDT (1158 PDT) in the MSEL, and 
VNN began to report on it at that lime, but it did not actually occur until ten minutes later. 

At any rate, the exercise epidemiological profile was nol developed to allow for the impact of counter-measures 
even if the exercise had lasted longer. 


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T2 


T2 did not have a tertiary population of cases, principally because the duration of the FSE was 
not as long as would have been needed for a set of tertiary cases to incubate and be present. 
Were a tertiary population to have been played, the secondary population role of healthcare 
workers would have been of the greatest importance, since this large secondary population would 
be important to spread of disease to the tertiary population. To the degree that the disease would 
have been spread within the population of healthcare workers, it takes a double toll, by 
increasing the population of the sick and decreasing the population of those able to care for them. 

5. The radiological dispersal device and Seattle weather 

Real radioactive materials were not released in the exercise. For the emergency workers to be 
able to respond realistically to readings from their instruments, these readings had to be pre- 
determined according to what the radiation levels would be. as functions of time and space, had 
an actual RDD been detonated. To predetermine these levels required atmospheric dispersion 
models (see also the description of these in the Special Topics section) to run in advance, which 
in turn required planners to make up weather prior to the FSE. FSE play was based upon this 
simulated weather rather than the weather that Seattle would actually experience on May 12, 
2003. In addition, planners desired that the plume disperse material to the west. 

6. Lack of 24-hour play 

In a real emergency, activity would have continued around the clock, especially in the first 
48 hours or so. During the FSE, some activities functioned around the clock, but others did not 
(e.g., importantly, the Seattle-area Joint Operations Center). As a result, participants were 
occasionally stymied when attempting to perform some function only to find that other 
participants were not playing at the time. These artificialities, particularly those that impacted 
decision-making and response activities, have been carefully noted in the exercise analysis. 

7. Pre-positioning of responders 

Various assets (such as teams from Department of Energy. Federal Emergency Management 
Agency (FEMA), the Federal Bureau of Investigation (FBI), and other agencies) were pre- 
positioned in the venues for reasons of safety, logistics, and cost. The evaluation team was able 
to account for advance deployments and ensure they were accounted for in the subsequent 
analysis. 

8. Varying Participation Schedules 

Numerous city, county, and State agencies participated in the FSE at different times during 
exercise play. As a result some activities that would usually occur in a coordinated fashion were 
disjointed. This resulted in agencies reaching differing conclusions and decisions at different 
times thereby created some degree of confusion. 

C. Artificialities That Arose During Exercise Play 

A number of artificialities arose during the execution of the exercise. In an exercise as large and 
complex as T2, this is not an unexpected event, and they were properly accounted for in the 
analysis of the exercise. 


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T2 


1. Chicago hospital play and the Metropolitan Health Care Council 

Chicago area hospitals participated enthusiastically in T2 play. Participation counted towards 
their accreditations’ exercise requirement. The Metropolitan Chicago Healthcare Council 
(MCHC) wa.s to provide role players to be Pneumonic Plague patients in area hospitals. At the 
same time, MCHC was to provide other role player patients, separate and apart from those 
participating in the FSE, for drills to be done by the hospitals as part of maintaining their 
accreditation. 

The addition of the extra patients by MCHC was not matched by an addition of extra control 
personnel. Artificialities arose when safeguards put in place by the T2 designers to avoid the 
blending of these two role player populations were not followed. The principal result was a 
distortion of the Pneumonic Plague scenario, with the unrealistic and uncontrolled number of 
additional cases that reduced the fidelity of play for those participants engaged in tracking the 
progress of the outbreak. The attempt to maintain two sets of records added confusion and may 
also partly by the end of the day on May 13, 2003, control staffs in the Illinois and Washington, 
D.C. Control Cells implemented measures to mitigate the impact. 

2. Issues with control 

During the FSE, there were several instances in which controllers took it upon themselves to 
modify the scenario, and in which other exercises or events unrelated to T2 briefly were believed 
to be part of T2 play. Again, these instances were documented and accounted for in the analysis. 

On D+2 somebody increased the threat posed by the Yersinia pestis plague bacterium, telling the 
Illinois venue players that their newest samples from the release sites contained live bacteria. 
Yersinia pestis does not survive for long outside of a host, so the presence of live bacteria at the 
release sites would indicate either a re-attack at the same site or a genetically modified Yersinia 
pestis that could survive lengthy exposure outside a host. In that neither a re-attack nor a 
modified germ was part of the scenario, the spurious report to the players qualifies as an 
artificiality. It had the potential to be an important one because it could have altered (but did 
not) the course of play and the decision-making of top officials. 

The scenario contained an incident in which investigators at the RDD site were to find a bomb- 
like object, which their notional investigation would then reveal not to be a bomb. These events 
occurred, but later another controller pronounced the device to be a bomb, leading to its 
explosive destruction by a remote-controlled robot. The on-the-spot creation of a second bomb 
represented a departure from the MSEL and — because of the implication that if there could be a 
second bomb, there may be a third — could have altered decision-making up the chain of 
command. 

Finally, there were several artificialities of control that occurred purely by accident, including at 
least two in which word of dire emergencies (e.g., the escape of a radioactive plume from a 
nuclear power plant in Ohio) actually leaked into FSE play from other simultaneously-running 
exercises, which were to remain separate from T2. 



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T2 


V. SPECIAL TOPICS 


During the Top Officials (TOPOFF) 2 {T2) Full-Scale Exercise (FSE), several sequences of 
events attracted great interest as they unfolded. Many represented truly experimental and 
groundbreaking elements of the response to a radiological or bioterrorism attack. These 
elements of response tended to cut across multiple areas of analysis, and the T2 evalu^on team 
decided that — given their salience — the best way to address them was to do so directly, telling 
the story and what was concluded from it. Some aspects of these stories also appear in their 
respective areas of analysis. 

These special topics are: 

• Alerts and Alerting: The Elevation of the Homeland Security Advisory System Threat 
Condition to Red; 

• Declarations and Proclamations of Disaster and Emergency; 

• Department of Homeland Security Play in T2: The Role of the Principle Federal Official; 

• Data Collection and Coordination: Radiological Dispersal Devise Plume Modeling and 
Deposition Assessment; 

• Play Involving the Strategic National Stockpile; 

• Hospital Play in the Illinois Venue: Resources, Communications, and Information 
Sharing during a Public Health Einwgency; 

• Decision-making under Conditions of Uncertainty: The Plague Outbreak in the Illinois 
Venue; and 

• Balancing the Safety of First Responders and the Rescue of Victims. 

Some of these topics overlap, but each account is written so that it may stand on its own. 



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T2 



32 



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T2 


A. Alerts and Alerting: The Elevation of the Homeland Security Advisory System Threat 
Condition to Red 


1. Introduction 

One of the most visible reactions to the events of 9/1 1 has been the 
creation of the color-coded Homeland Security Advisory System 
(HSAS). Real-world experience has included several transitions 
from Yellow to Orange, and back again.'” The national threat level 
has never been lower than Yellow or higher than Orange. Since a 
transition to Red has not yet occurred outside of exercise play, the 
Top Officials (TOPOPT) 2 (T2) exercise provided an opportunity to 
implement and analyze the role and impact of the HSAS Threat 
Condition Red. The U.S. Department of Homeland Security (DHS) 
has initiated the HSAS Working Group to review advisory system, as 
directed by Homeland Security Presidential Directive (HSPD)-3 and 
to examine the HSAS issues observed during the T2 Full-Scale 
Exercise (FSE). many of which are also discussed in thi.s Alter 
Action Report (AAR). 

In the FSE the threat condition was elevated to Red on five occasions, 
elevations (King County and the City of Seattle, Washington) immediately following the RDD 
explosion. The others were HSAS elevations by DHS; The City of Seattle on May 12, 2003. in 
response to its local elevation: seven .select cities late on May 12, 2003 (New York, NY: Los 
Angeles, CA: San Francisco, CA: Washington. D.C.; Houston, TX: Seattle. WA: and Chicago, 
ID: and finally, a nationwide elevation on May 13,2003. On May 14, 2003, DHS downgraded 
the threat condition from Red to Orange nationwide except for New York City and Chicago. 

T2 was groundbreaking jn several areas with respect to the HSAS: It represented the first 
opportunity for agencies to experiment with the actions associated with an elevation to Red: it 
allowed for examination of the implications of elevating regions to Red; it included local 
jurisdictions raising their own threat conditions to Red; and it highlighted that additional 
refinement of the system is needed. This section attempts to document how these events 
unfolded during the T2 FSE and what happened as a result. It is intended to promote learning 
and improvements with the continuing implementation of the system. 

2. Background 

HSPD-3 established the HSAS. which is “intended to create a common vocabulary, context, and 
structure for an ongoing national discussion about the nature of the threats that confront the 
homeland and the appropriate measures that should be taken in response." The system uses 
colors (from green to red) to define threat levels from low to severe. Table 3 shows the HSAS 


The fact that the National Direction and Control Seminar and the Full-Scale Exercise each took place during 
Orange alert.s underscored to the players and others the urgency, relevance, and realism of T2. who.se scenario 
included a transition from Yellow to Orange and up to Red, 



The initial two were local 


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T2 


colors, labels, and the associated risks and the protective actions Federal departments and 
agencies should consider with each assigned threat level. 

Table 3. Homeland Security Advisory System 


Color 

Label 

Level of 

Risk 

Protective Action Guidelines 

GREEN 

LOW 

Low risk of 

terrorist 

attacks 

Federal departments and agencies should consider the following general measures in addition to tlie agency- 
specific protective measures they develop and implement: 

• Refining and exercising as appropriate preplanned protective measures: 

• Ensuring personnel receive pn^r (raining on the Homeland SecBOly Advisory SystKiand specific 
preplanned department or agency protective measures: and 

• Instilulionaliring a process lo assure (hat all facilities and regulated sectooBR regularfy assessed fur 
vulnerabilities to lerrorisi attacks, and all reasonable neasures are taken (OSliligaie these vulnerabilities. 

BUIE 

GUARDED 

General risk 
of terrorist 
attacks 

In addition to the proteclive measures taken in (he preiipus Threat Condidon. Federal departments and 
agencies should consider the following general {ncasura in addition to the agency-spcciric protective 
measures that they will develop and implement: 

• Checking communications with designated eatargencyiv^oose or command locations: 

• Reviewing and updating emergency respoBse procedures: and 

• Providing the public with any information lliM wouIA strengthen ils ability to act appropriately. 

YELLOW 

ELEVATED 

Siftnificant 
risk of 
terrorist 
attacks 

In addition to the proteclivniBBHSures taken in the previous Threat Conditions. Federal departments and 
agencies should consider the fbOowing general measures in addition to the proteclive measures that they will 
develop and impleaeni: 

• Increasing survcinuceofcrMctliDoarions: 

• Coordinating emergency plans as appropriate with nearby jurisdictions: 

• Asiessfiigvitelher ihe precise characteristics of the threat require the further refinement of preplanned 
proMctisc mNHmaad 

• liiipIcnMniing. as appropriate, contingency and emergency response plans. 

ORANGE 

HK« 

1 

High risk of 

terrorist 

attacks 

In addition to die proteclive measures taken in (he previous Threat Conditions. Federal dcpartineiits and 
agencies should Consider the following general measures in addition to (he agency-spccific protective 
flMMMa that they will develop and implement: 

• Coordinating necessary security efforts with Federal. Stale, and liKal law enforcemeni agencies or any 
National Guard or other apprt^riaie armed forces organisations: 

• Taking additional precautions at public events and possibly considering ahemulive venues or even 
cancellation: 

* Preparing to execute contingency procedures, such as moving to an alternate site or dispersing their 
workforce: and 

* Restricting threatened facility access to essential personnel only. 

RED 

SEVERE 

Severe risk 
of terrorist 

attacks 

Under most circumstances. Ihe protective measures for a Severe Condition are not intended to be sustained for 
substantial periods of time. In addition to the protective measures in the previous Threat Conditions. Federal 
departments and agencies also should consider the following general measures in addition lo the agency- 
specific protective measures that they will develop and implement: 

• Increasing or redirecting personnel lo address critical emergency needs: 

• Assigning emergency response personnel and pre-positioning and mobilizing specially trained teams or 
resources: 

• Monitoring, redirecting, or constraining transportation systems: and 

• Closing public and government facilities. 


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T2 


The original directive authorized the Attorney General to assign the threat condition. HSPD-5 
amended HSPD-3. such that: 

Threat Conditions shall be assigned by the Secretary of Homeland Security’, in 
consultation with the Assistant to the President for Homeland Security. Except in 
exigent circumstances, the Secretary of Homeland Security shall seek the views of 
the Attorney General, and any other Federal agency heads the Secretary deems 
appropriate, including other members of the Homeland Security Council, on the 
Threat Condition to be assigned. 

The greater the perceived risk of a terrorist attack, the higher the threat condition. According to 
HSPD-3. risk includes both the probability of an attack and its potential gravity. Decisions as to 
what Threat Condition to assign should, therefore, take both of these factors into account. 
HSPD-3 states that the evaluation of the Threat Condition is qualitativ e_an d shall include, but not 
be limited to. the following factors: 

• To what degree is the threat information credible; \ 

• To what degree is the threat information corrobor^dp<[^ 

• To what degree is the threat specific and/or imminent; 




How grave are the potential consequences of the threat? 


HSPD-3. as amended by HSPD-5, also authorizes the Secretary of Homeland Security, in 
consultation with the Assistant to the President for Homeland Security, to decide whether to 
publicly announce the threat condition level on a case-by-case basis. Threat conditions may be 
assigned for the entire nation, or they may be set for a particular geographic region or industrial 
sector. 

HSPD-3 also directs Federal agencies and departments to implement appropriate protective 
measures according to the threat condition. Each department and agency is responsible for 
developing their own protective measures, and they also retain the authorities to respond, as 
necessary, with their specific jurisdictions as authorized by law, 

The HSAS is only binding on the executive branch of government. It does, however, encourage 
governors, mayors, and other leaders to review their organizations and assign protective 
measures to the threat conditions, in a manner consistent with that of the Federal Government. 
For example, some states, such as Illinois have developed formal guidelines with specific 
security measures that are to be implemented under each of the HSAS color codes. In Illinois, 
the Slate Emergency Operations Center (EOC) determines the appropriate response actions and 
security recommendations after any elevation and transmits them to county and municipal 
agencies. The State of Illinois exercised this system during the FSE. 


3. Reconstruction 


The FSE scenario called for an elevation of the nationwide threat condition from Yellow to 
Orange. It occurred as scheduled by controller inject at 1000 Eastern Standard Time (EDT) on 
May 6, 2003, in response to scripted credible and corroborated information indicating a grave 
and imminent terrorist threat. By contrast, the transitions that look place during the exercise 
from Orange to Red occurred as player actions, not as Master Scenario Events List (MSEL) 


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T2 


injects, and accordingly happened when the players decided it was appropriate. Figure 5 depicts 
the various alert elevations to Red during the FSE, including local elevations. 


Homeland Security Alert Status Timeline 



(i6fl260T) (WflOEOn 

(1W5 EOT) 


Figure 5. Homeland Security Alert Status Timeline 
a. Local and regional threat condition elevations 

Shortly after the radiological dispersal device (RDD) explosion. King County and the City of 
Seattle effectively elevated the threat condition to Red in their respective jurisdictions. The City 
of Seattle activated its HOC to Phase 111 immediately in response to the blast. The King County 
EOC posted its elevated threat condition at 1240 Pacific Daylight Time (PDT) on May 12. 2003 
and distributed an e-mail announcing the elevation at 1319, stating, "The threat level is raised to 
Red.” Local officials announced a regional elevation for Seattle and King County on the Virtual 
News Network (VNN) around 1630 PDT. 

Data indicates that DHS learned of Seattle and King County's intent to raise their alert levels as 
early as 1600 EDT. Several data points suggest that DHS responded to this by initiating an 
elevation of the HSAS to Red in Seattle. The only formal documentation of this was found in a 


36 


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T2 


DHS/Transportation Security Administration (TSA) log at 1935 EDT, which reported that DHS 
elevated the HSAS to Red in Seattle.^' 

Substantial confusion followed these first elevations. Many participants in ail venues assumed 
the first local elevations were initiated by DHS and that they applied to the nation. Uncertainty 
regarding the alert status of King County, Seattle, and Washington State ensued for almost 24 
hours as agencies sought to confirm the specifics. The confusion even spread to at least one of 
the exercise control cells. At 1940 PDT on May 12, 2003, a controller told the WA State EOC 
that the nation was at Red (which it was not at this time), fueling the confusion. 

Meanwhile, the City of Chicago and the State of Illinois experienced brief, false elevations to 
Red. For example, around 1500 Central Daylight Time (CDT) on May 12, 2003, the Chicago 
Department of Public Health notified the Chicago Office of Emergency Management (OEM) of 
an unconfirmed Red Alert. The Illinois Department of Public Health (IDPH) notified the 
Chicago OEM of an unconfirmed Red Alert soon thereafter. This may have been triggered by 
the belief that the nation was elevated at the time of the Seattle/King County elevation or 
separate elevation within the health alert system which is also color-coded. Over the next two 
hours, the HSAS threat status was ultimately confirmed as Orange: 

• At 1535 CDT the Director of the Chicago OEM advised that the elevation to Red was 
unconfirmed and gave instructions to “hold at Orange pending formal notification 
through the HSAS system”; 

• By 1600 CDT the Chicago and State EOCs had confirmed the HSAS threat level was still 
at orange; and 

• At 1711 CDT. the Chicago EOC distributed a message that the HSAS threat level was 
still Orange. 

b. Seven-cities threat elevation 

Later in the evening of May 12, 2003, the Secretary of DHS decided to rai.se the HSAS threat 
condition for seven cities including Seattle and Chicago based upon intelligence that indicated a 
severe risk of terrorist attacks in those areas. A DHS Crisis Action Team (CAT) situation report 
and e-mail distributed at 2030 EDT noted that: 

DHS advised that effective at 2130 EDT (1930 CDT/I830 PDT) on today's date, 
the alert level will be raised to Code Red for the following cities: Seattle; San 
Francisco; Los Angeles; Houston: Chicago; New York; Washington, D.C. 

Around 2145 EDT, die Secretary of DHS announced on VNN that DHS had done an assessment 
of the need to take additional preventative action “throughout the country” and had “raised alert 
in the six cities along with King County (WA), and the City of Seattle.” This appeared to be pre- 
coordinated by DHS with other agencies, as many entities, but not all, knew before the formal 
announcement on VNN. Some were still confused about the status of Illinois and Washington in 
light of this, and there was some confusion in the WA State EOC as to whether this applied to 
the City of Seattle and King County as well. 


The analysis team attempted to confirm this information via phone calls but did not receive a response by the 
publication of this draft report. 


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T2AAR 


T2 


Agencies were uncertain about the impacts of a DHS elevation of the HSAS to Red in 
Washington, and local jurisdictions and began inquiring about “what would DHS close” and the 
impacts on airspace and ports, among other systems. There were some breakdowns in 
communication: the Principle Federal Official (PFO) in Washington noted that there were no 
messages coming from DHS to the Joint Information Center (JIC) or Joint Operations Center 
(JOC) related to this elevation prior to the VNN announcement. Also, a Federal Emergency 
Management Agency (FEMA) log referred to “breaches of protocol” in notification procedures. 

c. Nationwide 

On May 13, 2003, VNN reported between 1445 and 1545 EDT that the Secretary of DHS was 
considering raising the entire nation to Red. At 1530 EDT, a member of the DHS CAT noted 
that: 

The CAT leader passed results of meeting with Secretory Ridge — he will 
recommend to President that all three Chicago airports... rail/trains he closed, 
intercity buses be closed down, mass transit wdl remain open, highways will 
remain open. Also recommended red nationwide, hut transportation systems 
nationwide will not he closed to keep .supply chains open. 

The DHS Office of International Affairs received similar information from TSA. 

At approximately 1600 EDT, the Secretary of DHS initiated a nationwide elevation to Threat 
Condition Red when it became clear that the entire country could be under attack. A DHS 
“ALERT AL-03-TOPOFF2-M” formal memorandum recorded this as follows: 

The Secretary of DHS. in consultation with the intelligence community and the 
Homeland Security Council, raised national threat level to Code red nationwide 
as of 1600, May 13 due to the RDD detonation and the Pneumonic Plague release 
in Chicago and receipt of credible information that additional attacks may be 
planned. ..Federal Departments and Agencies, and Stale and local authorities, are 
directed to immediately Implement protective actions identified in Operation 
Liberty Shield... 

The Secretary of DHS appeared on VNN at 1 800 hours EDT to announce the elevation of the 
nation to Red. 

Following this news, the Illinois State EOC initiated the State of Illinois alert system and 
provided detailed instructions to the City of Chicago and collar counties. Using a standardized 
communications system and operating procedures, Illinois’ participating agencies initiated a 
response to the threat elevation. 

The Director of the WA State EOC heard about this DHS action via VNN; he did not receive any 
formal notification from DHS before the Secretary's speech. He also did not receive any written 
guidance about the impact on transportation systems or whether public events should be 
cancelled. As of 1900 PDT. top officials in the WA State EOC had still not received formal 
confirmation of the elevation. The Joint Operations Center (JOC) contacted King County 
looking for a copy of the speech or formal documentation. The Seattle and King County EOCs 
also learned about the elevation through VNN and expressed some frustration at the lack of 
formal notification. 


38 



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T2 


The apparent lack of formal notification led to continued misunderstandings about the scope of 
DHS's action. There was some speculation in the Seattle EOC that perhaps the latest 
announcement applied to Chicago only: “Suspect this message was garbled and pertains to 
Chicago only. Request DHS fax us paper on condition of Red Statement. . .” At 1 700, a Seattle 
EOC data collector noted a DHS acknowledgement that it did not follow proper notification 
protocols: “DHS agrees that they did not follow procedures to notify top officials. . .” 

There was widespread confusion at all levels of government regarding the actions to take in 
response to the DHS elevations to Red, as well as confusion regarding the actions Federal 
agencies were expected to take (e.g., closing airspace). Many Federal, State, and local (FSL) 
agencies looked to DHS for specific guidance, as the following four examples illustrate: 

1. From notes on a discussion among local top officials in the Seattle EOC of the 
nationwide elevation to Red on May 13, 2003: 

What is working and what is not. ..what does stay at home for 48 hours mean? 
Who maintains water, power, and ho.spital serx’ices? etc. ..Will feds shut down the 
airports? Interstate commerce. Ports? We are not sure what 'go home for 48 
hours' means? ...We need to go back to the Feds, DHS and ask for clarification 
on what is key and essential personnel. ■ . We need to determine what to say in a 
press release... 

2. Late the evening of May 13, 2003, the WA State EOC formally requested guidance 
through DHS/FEMA on what is required under a the HSAS Threat Condition Red: 

Specifically, the State needs clarification on what Protective Measures are 
contemplated for Federal facilities by Homeland Security ...” and “The State 
EOC is aware it needs to notify the public of its position based upon the Ridge 
position, but is not clear on what this position is. 

3. From an Environmental Protection Agency EOC discussion on Condition Red at 0800 on 
May 13, 2003: 

Security guidance says people are supposed to report to work unless otherwLie 
notified. The question is what we tell employees. We need a decision pretty 
quickly as there will be panic. Action would be to call DHS for guidance on the 
Federal area. 

4. From the Veteran’s Affairs Central Office on May 13, 2003: 

Does Safe Harbor address what to do when threat level increases in only certain 
places - clarification language to be added to op plan - we need to monitor other 
cities that have elected to raise threat level themselves & notify facilities... 

Even within DHS there was some uncertainty of what actions to expect and guidance to issue 
under Condition Red: 

• “The DHS Emergency Preparedness and Response (EP&R) desk requested from agency 
as to what is expected of the Slates under ThreatCon red”; and 

• From the Homeland Security Center Incident/Information/Operational Response Report 
received from FEMA Emergency Support Team (EST) on May 14, 2003, at 0255 EDT: 


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T2 


The FEMA EST is requesting guidance as to what are the expectations of the states 
under Threat Condition Red. For the record, earlier tonight, upon notification that 
the entire nation was at a Code Red threat level, the EST followed the checklist 
included in the above referenced notification to simulate play in support of TOPOFF 
2. We have subsequently received an inquiry from the State of Washington as to what 
is expected of the states at level Red. With this e-mail, we are forwarding this to your 
attention as your input will be needed to best answer these questions! 

d. Downgrade to Orange for most of the United States 

At 1615 EDT on May 15, 2003, FEMA e-mail traffic noted that the DHS Secretaiy directed the 
nationwide HSAS Threat Condition returned to Orange except for Chicago and New York City; 
these two cities remained at Red.^^ The first documentation of this notice within Illinois was 
from the Chicago Department of Health and Human Services (HHS) to the Chicago OEM at 
1515 CDT. The Chicago OEM received formal notification from FEMA Region V at 1550 
CDT. 

4. Artificialities 

• Some of the above data suggests an exercise control problem. For example, a WA State 
EOC shift change briefing stated, “controller inputs are not being backed by operational 
inputs.” This reflects a problem with the flow of information through the control and 
play chains. There is at least one instance of controller interference with the WA State 
EOC’s understanding of the threat level, which contributed to some of the confusion.^"' 
While players were expected to obtain information through proper channels, some of the 
data did suggest controller interference at variou-s locations and times in what may have 
been misguided attempts to help the proce.ss. 

• Not all agencies were fully staffed for the FSE as they would be under an actual threat 
condition of Red; A FEMA Regional Operations Center (ROC) data collector log noted: 

In reality the Disaster Field Office (DFO) and ROC would be fully staffed (at the 
Red threat level): we would have discussions with the State, county, etc. about 
what they 're having to deal with. . . 

• At 1515 CDT on May 14, 2003, the Command Group at the JOC in Illinois was informed 
by FEMA/DHS that the threat condition had been downgraded to Orange except for 
Chicago and New York City. They began to implement the appropriate changes when 
this was retracted and they were notified that the nation was still at Red. This may have 
been a situation where players were outpacing the MSEL. 

• The Illinois State and Chicago EOCs closed for the night at 1700 and 1800 respectively 
on May 12, 2003. This resulted in an artificial delay in formal transmission of the news 
to the collar counties of the seven-city elevation. 

• The absence of an active news-gathering mechanism, described in more detail in the 
Artificialities section of this AAR. may have contributed to some confusion regarding the 


The Washington venue was no longer playing at this time. 

From WA State EOC Data Collector log; “National Controller called EOC supervisor to tell him the national 
threat level went Red-Effective 1740. This was an inject. 



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T2 


elevations as well, specifically early on in local King County and the City of Seattle 
where local elected officials were not able to broadcast this message widely. 

• The FSE did not exercise FSL agency Continuity of Operations Plans (COOP), which 
some agencies may have implemented had this been a real attack or if they were under a 
real Red Alert. Such plans involve the emergency relocation of offices to alternate 
facilities depending on the emergency and threat. If even a few key agencies 
implemented COOPs, the communications, coordination, and connectivity issues 
experienced by agencies during the FSE would have likely multiplied, as agencies are not 
familiar with other agencies’ COOP procedures and these procedures are rarely exerci.sed 
across the national response community. 

5. Analysis 

As the reconstruction makes clear, a number of critical HSAS issues arose during the FSE 
events. In particular, there was pervasive uncertainty over the status of threat conditions in the 
various jurisdictions. While some confusion was controller-induced, this does not account for 
the principal impact. There wa.s uncertainty over what actions should be taken at Red. The 
rationale behind the elevations was not always clear to the players. Another issue apparent in the 
data was concern over the costs of maintaining a threat condition of Red. Finally, many critical 
public policy decisions were made during this period of uncertainty of threat conditions and 
public information on the subject was not clear. 

a. Confusion about the threat condition status of jurisdictions 

This is perhaps the most pervasive problem and the confusion appears to have grown with each 
successive elevation. When King County and Seattle first raised their local threat conditions to 
Red. confusion began to spread in Washington State. Many (including data collectors and. 
importantly, controllers"'*) assumed that DHS had raised the HSAS for the entire nation (the 
HSAS Threat Condition was elevated for just Seattle). Others wondered if Washington State 
was at Red (it was not until the nationwide elevation was initiated by DHS). Data suggest that as 
late as 0245 PDT on May 13, 2003, the WA State EOC was still trying to confirm the threat 
condition status of Seattle at Red and Washington State at Orange. The Washington National 
Guard log and JIC data collector logs finally confirmed a consistent understanding of threat 
status for the city, county, state, and nation by 0737 PDT on May 13, 2003, (Seattle and King 
County were Red, and the state and nation were Orange). Many assumed again the entire nation 
was elevated to Red when the threat status of the seven cities was elevated. 

b. Confusion as to what actions to take under a red alert 

During the FSE, there was widespread confusion at all levels of government regarding specific 
protective actions to be taken under HSAS Threat Condition Red. This included actions that 
should be taken by a particular agency as well as what actions others were implementing. 
Federal agencies such as FEMA, Department of Transportation, HHS, and others have well- 
developed action plans for TTireat Condition Red. FEMA has checklists that have been 
developed, and it simulated the usage of them during the exercise. However, Federal plans do 

This is relevant to the analysis to the extent that some of the data collector accounts were inconsistent as their 
interpretations of messages broadcast on VNN differed as did participants. Further, controller confusion resulted in 
at least one false inject. 


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not all carry the same level of detail, and may not be widely or consistently understood by other 
Federal agencies, State and local governments, the private sector and the general public. Many 
agencies looked to DHS for clarification as to what actions they should take, and what actions 
the Federal Government would be taking, under a Red Alert. 

The language in HSPD-5 states that the HSAS is only binding on Federal agencies and that those 
agencies are responsible for developing their own specific protection measures to meet the 
guidelines of the HSAS. Furthermore, HSPD-5 is not binding on State or local governments, but 
encourages them to develop their own protective action strategies. But this flexibility also means 
that no single agency at any Federal, State, or local level of government has a consistent and 
comprehensive understanding of the protective actions that might be taken by other agencies 
under Red. Further, the potential impacts of protective actions taken by an agency or jurisdiction 
on other agencies or jurisdictions are not well understood. The confusion is magnified when the 
Federal HSAS and State/local elevations intersect and are not synchronized. For example. 
Federal and State agencies in Washington were temporarily uncertain as to their status after the 
local Seattle and King County elevations to Red. When the nation was elevated to Red by DHS. 
State and local agencies were uncertain as to the impact on them. 

Participants in the T2 After Action Conference (AAC) suggested the development of an 
escalating scale of operational response linked to the HSAS kvels. This system would be 
defined by a federation of FSL agencies and would offer a comprehensive operational response 
framework that jurisdictions at all levels could use to help define their response plans for each 
threat level. Such an operational framework would help to increase the consistency of measures 
taken across the nation, while preserving the flexibility of the system overall. It would help to 
ensure that all jurisdictions, regardless of their potential specific decisions on how to respond to 
various elevations, are at least considering common families of protective measures in those 
decision processes. 

c. Some confusion may be due to unclear language 

While threat conditions under the HSAS may be set for a particular geographic area or industrial 
sector, it is generally referred to as the “national threat level," possibly contributing in some 
cases to assumptions that it applies to the entire nation rather than specific areas. During the 
FSE, the term national in reference to the DHS Threat Condition appeared to be interpreted two 
different ways: 

• it applied to the entire nation (which was not the case in initial HSAS elevations); and 

• It referred to the national threat level recommendation system, which could apply to 
specific localities/jurisdictions/regions. 

The term regional was used and interpreted in as many as five different ways; 

• DHS had raised the threat condition for some regions which were not clearly specified, 
and which may not have been along clear jurisdictional boundaries; 

• DHS raised the threat condition for one or more local jurisdictions (e.g.. King County and 
Seattle); 

• Local jurisdictions raised threat conditions on their own; 


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• DHS raised the alert level for certain, specific cities (e.g., when the alert level was raised 
for seven cities, some referred to this as a regional elevation); and 

• A regional Red Alert was instituted for Washington State, while the nation was still at 
Orange. 

d. Formal notification procedures were not consistently employed or understood 

Another potential source for confusion lies in the area of communications and coordination; 
formal notification procedures for changes to the HSAS Threat Condition, and State/local threat 
conditions were not consistently implemented or well-understood across FSL levels of 
government. Many participants relied on informal communications. While there is some 
evidence of formal communications, they were obscured in many cases by the volume of 
independent informal communications occurring in parallel. Even organizations that are part of 
the formal notification chain found it difficult to confirm and validate information they were 
hearing amid the volume of communications.^^ Most participants (with the exception of DHS) 
received much of this information from VNN, and relied on this information in many cases. If 
agencies had shared a common understanding of a formal notification approach, one might have 
expected to see similar approaches to validate the informal reports they were receiving regarding 
changes in the threat condition status. 

Some attempts were made to validate information, but many organizations acted on information 
they received through informal channels. The DHS PFO in Washington helped greatly to dispel 
confusion over alert elevations and to improve communications overall once he was in position 
by acting as a direct conduit to DHS and helping to streamline communications. 

e. Concern about the financial and otiier costs associated with implementing and 
maintaining High or Severe levels of the alert system 

During T2, many agencies attempted to quantify the costs of implementing Threat Condition Red 
and many raised this concern at the AAC. Some agencies sought to obtain reimbursement for 
these costs through various means. The data show that DHS was concerned about the potential 
unintended consequences of threat elevations including new vulnerabilities that could be created 
by reallocating resources from one focus to another. Some of the issues being addressed by the 
DHS-initiated HSAS Working Group are the economic and social implications of an elevated 
threat level. 

f. Uncertainty over rationale for the various elevations 

Uncertainty may be related to both the lack of formal notification and the lack of understanding 
about what protective measures to take in response at red. Some agencies argued that specific 
information was needed to identify what actions to take. For example, the following comment 
comes from the WA State EOC: “People come in all alarmed because DHS wants to go to Red 
Alert nationwide. No one knows why but that requires Americans to stay home for 48 hours. . .” 

The concern about the lack of specific intelligence accompanying many real-world threat 
elevations was also voiced at the AAC. Some of this is due to a lack of specificity or to 


At 2146 hours PDT on 12 May 03, a FEMA ROC Data Collector reports that “the State had received a message 
saying all of US on Red ...been trying to track where info came from and get right info.” This same log also noted a 
belief that the entire nation remained at orange when by this lime seven cities had been elevated to Red. 


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information security in source intelligence, issues currently being addressed by DHS. But 
increased coordination between DHS and the states and localities on the nature of threats severe 
enough to merit increased elevations in the threat system to their jurisdictions, particularly to 
Red, are crucial to a response that minimizes unintended consequences and maximizes the use of 
limited resources towards an increased protective posture. 


g. Many public policy decisions were made during this time of uncertainty 

Numerous decisions were made during this period of uncertainty — some of which would have 
seriously challenged the agencies’ abilities to maintain credibility and implement public policy 
objectives given the widespread lack of understanding of the threat condition status. This could 
have had dramatic impacts on messages to the public as well. For example, word of an elevation 
to Red that was later reported to be incorrect likely would have caused some alarm. Decisions to 
re-open transportation corridors, such as the airspace in Seattle, would have been confusing, in 
light of a national condition of Red or even a continued city-wide condition of Red. The 
potential public policy implications of elevations to Red at all levels of government further 
underscore the importance of a coordinated, synchronized, operational response to HSAS 
elevations. 


A 


h. Public information was unclear 

Many of the issues highlighted above would have had inlets on the effectiveness, 
comprehensiveness, and consistency of messages delivered to the public by top officials. 
Participants reiterated at all of the T2 seminars the importance of consistency and 
comprehensiveness of messages for establishing and maintaining top official and spokesperson 
credibility, Top officials’ public announcements, while limited, did not provide specific 
information to the public about what to do at Red or how agency actions and protective measures 
differ at Red, as Threat Condition Red relates to one at Orange. The DHS Secretary’s speech 
that elevated the national threat condition to Red did not explain why people in Topeka, Kansas 
(for example) could be at the same level of risk as those in the affected areas or other higher-risk 
areas, such as New York City. In their public announcements. State and local officials did not 
clarify the local nature of the initial elevation to Red and the implications therein. Further, there 
was no mention in any of the public announcements of a synchronized FSL agency response to 
the elevations (at present this is an issue as described in part b. of this section). 

A consistent and comprehensive operational response at all levels of government would be key 
to building confidence in the overall protective posture. Public perception of a comprehensive 
and consistent operational response would be especially important for top officials if, as was the 
ca.se during the FSE and the Large-Scale Game (LSG), an attack were to occur in a jurisdiction 
that was under an elevated threat condition. The HSAS system cannot ensure against all future 
attacks, and is not one hundred percent failsafe. Its value and goal is two-fold: (1) increase the 
overall protective posture to reduce the risk of a terrorist attack; and (2) build public confidence 
in the government’s ability to protect the public and provide a sense of safety and security. 


Both the value and goal of the HSAS and the credibility of government top officials, depend 
upon a comprehensive operational respon.se at all levels, as well as the public’s belief that the 
government is indeed doing/has done everything in its power to effectively reduce the risk of 
such an attack. DHS may want to consider joint press conferences in future announcements of 
local or regional elevations of the HSAS that include the top officials of those jurisdictions, as 


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well to reinforce the public’s confidence that a comprehensive response is underway. Further, to 
the extent that any part of the country, much less the entire nation, is ever at a sufficiently severe 
risk of attack to merit an elevation of the HSAS to Red, top officials must explain the nature of 
this risk as clearly as possible without compromising national security. Such information is 
critical to maintaining the credibility of the HSAS system and to obtaining the desired public 
response to such an elevation, which is a key component (along with FSL agency protective 
actions) to minimizing both the likelihood and potential human consequences of an attack. 

A final issue with public information was the timing and delivery of the news regarding the 
unprecedented elevation of the nation to Red. This news was delivered at the end of the DHS 
Secretary’s speech after numerous other general status updates and a recap of the previous day's 
“seven-city” elevation. Many would expect an announcement of this magnitude and gravity to 
lead to such a speech. Additionally, the public was not fully engaged by the Federal Government 
during the exercise about what actions it should be taking as the HSAS was increased. The 
American Red Cross, however, did post recommended actions the public .should take under the 
different threat levels on its website, and established a call center for guidance. 

6. Conclusions 

HSPD-3. amended by HSPD-5. specifically recognizes “th^ roles and responsibilities of State 
and local authorities in domestic incident management” and their “initial responsibility” for 
incidents. The HSAS is described as a 
"flexible” system with the purpose of 
providing a “common vocabulary.” and State 
and local jurisdictions have been encouraged 
to adopt the system. It is further described as 
a “national framework,” intended to help 
unify various sector-specific alert systems 
already in existence. 

The T2 FSE highlighted that additional 
refinement of this system is needed. 

Agencies at all levels were not certain what 
actions to take in response to Red. or what 
actions were being taken by other FSL 
agencies. As participants at the AAC 
emphasized, and as the FSE demonstrated, a 
more common and systematic, but flexible, 
framework for implementing protective 
measures is needed. Development of an 
“operational response” system, tied to the 
escalating alert levels of the HSAS, could 
help increase the overall protective posture 
taken at each level of government, and 
increase the overall situational awareness of 
top officials across a specific jurisdiction or 


Sl’M.MARY OF CONCLl'.SlON> 
A1.KRTS AND ALKRTINO: 


HSAS elevations should be pre-coordinated and 
synchronized with affected states/localities. There 
was widespread uncertainty as to the HSAS status 
until the nationwide alert on May 13. 

Critical public p>olicy decisions were made during a 
period of uncertainty on HSAS threat status. 

Top officials lacked “situational awareness" and a 
“common operational picture" of relative increase in 
civil protective posture in response to condition red. 
Agencies recommend development of a parallel 
system of operational response linked to the HSAS 
levels. 

Increased coordination is needed between DHS and 
states/localities on nature of threats, to minimize 
unintended consequences and cost-effectively 
increase the overall protective posture. 

Agencies do not have or share consistent understanding 
of formal notification approaches for HSAS status 
changes. 

Public information messages regarding HSAS 
elevations should be clear, consistent, and explain 
comprehensive FSL response actions, as well as 
recommended actions for the general public to take. 


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region. Such a common operating picture across all levels of government requires improved 
communication and coordination; standard terminology and pre-designated action plans or 
checklists for all agencies may help in this regard. 

Elevations of the HSAS should be synchronized (in purpose, place, and time) with States and 
localities, and their elevations in-line with the HSAS — specifically when alert conditions at these 
levels may differ, even if temporarily. Local communities will immediately implement Red- 
equivalent emergency procedures in the aftermath of any attack, as was done during the FSE, but 
coordinating these actions with DHS and the broader HSAS framework needs additional 
refinement. Further, elevations of the HSAS should be closely coordinated with the affected 
State and local jurisdictions beforehand. An HSAS elevation to Red will have impacts upon 
affected States and localities — States and local jurisdictions may feel pressure to respond even if 
they don’t perceive the threat to merit such an elevation in their particular jurisdiction. Such 
consultation can help to ensure that protective actions are implemented in the most cost- 
beneficial manner appropriate to the nature of the threat. 

Agencies did not share a consistent understanding of the HSAS status of the nation or their 
jurisdictions until the nationwide elevation on May 13, 2003. This was due to communications 
issues — both the absence of a shared understanding of formal notification procedures, as well as 
inconsistent language. In some cases, formal notifications occurred between DHS and the states, 
between states and local jurisdictions, and between State/local jurisdictions and DHS. However, 
this was not always the case and it did not appear to occur with consistency. 

While the media is sometimes the first means by which government agencies will learn of major 
events and threat elevations, formal notifications are imperative for transmitting information as 
critical as alert elevations, and certainly one to Red. Agencies must all be fluent in formal 
processes and know to treat anything not received through them as unconfirmed. Periods of 
uncertainty could delay the implementation of some protective actions and impact public 
information. Not only might inconsistent messages and decisions impact the credibility of 
elected officials, it could undermine the effectiveness of public safety campaigns. Further, the 
extended time spent confirming the threat status through multiple channels diverted energy from 
other agency priorities. 

Also, language must be clear and consistent. The term national threat level was assumed by 
some to refer to any threat elevations regardless of their geographic scope or the source of the 
FSL action. When people heard the national level was raised, many assumed this refened to its 
geographic scope and assumed the entire nation was at Red when it was not. In some cases 
elevations initiated by local or State jurisdictions were referred to as regional elevations and 
people were not clear about the boundtiries. Some described the seven-city elevation as a 
regional elevation. The precise scope and nature of threat elevations, since they may vary, need 
to be explicitly clear to reduce confusion. 

Finally, some implications of Red, such as agencies implementing COOPs, were not played and 
would have further complicated operations. In the event of an attack, many agencies would 
implement COOPs under the HSAS Threat Condition Red. This reinforces the need to have a 
tightly orchestrated set of procedures that all agencies understand. Future exercises should 
include continuity of operations and continuity of government objectives to address these 
challenges as well to ensure maximum realism. 


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B. Declarations and Proclamation of Disaster and Emergency 


1. Introduction 

During the Top Officials (TOPOFF) 2 (T2) 

Full-Scale Exercise (FSE), several 
declarations and proclamations of 
emergencies and disasters took place. Local 
jurisdictions in both exercise venues 
invoked their authorities to declare 
emergencies, and requested federal 
assistance under the Stafford Act (see 
below). These requests ultimately led to a 
Presidential Declaration of Major Disa-ster 
in Washington and one of Emergency in 
Illinois. In addition, the Department of 
Health and Human Services (HHS) declared a Public 
authorities of the Public Health Service Act. This section 
declaiations, as well as related issues that arose during the 

2. Background 
a. The Stafford Act 

Stafford Act declarations generally start with a reque.st from a governor. Requests for 
declarations of both emergency and major disaster must “be based on a finding that the disaster 
is of such severity and magnitude that effective response is beyond the capabilities of the slate 
and the affected local governments and that Federal assistance is necessary.’’*^ A Major Disaster 
is defined in the Stafford Act as 

...any natuml catastrophe (mduding any hurricane, tornado, storm, high water, 
wind driven water, tidal tsunami, earthquake, volcanic eruption, landslide, 
mudslide, snowstorm, or drought), or regardless of cause, any fire, flood, or 
e.xplosion. in any part of the United States, which in the determination of the 
President cau.ses damage of sufficient severity and magnitude to warrant major 
disaster assistance under this chapter to supplement the efforts and available 
re.sources of states, local governments, and disaster relief organizations in 
alle\'Uiting the damage, loss, hardship, or suffering caused thereby. 

Stales may be reimbursed for up to one hundred percent of qualifying expenses under a 
Presidential Declaration of Major Disaster. 

An Emergency is defined as 

...any occasion or instance jar which, in the determination of the President, 
federal assistance is needed to supplement state and local efforts and capabilities 



The Robert T. Stafford Disa.ster Relief and Emergency A.ssislance Act, As Amended. 42 U.S.C. 5 1 2 1 , et seq., 
htlp : //www . feina.gov71ibrjr\7slafact. shlm . 


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to save lives and to protect property and public health and safety, or to lessen or 
avert the threat of a catastrophe in any part of the United States. 

Federal assistance under a Presidential Declaration of Emergency is limited to five million 
dollars except in circumstances where the President determines that: 

• Continued emergency assistance is immediately required; 

• There is a continuing and immediate risk to lives, property, public health, or safety; and 

• Necessary assistance will not otherwise be provided on a timely basis.^^ 

Other differences include limitations in public assistance (emergencies allow only for emer^ncy 
debris removal and emergency protective measures, and not for permanent repair and 
replacement work), disaster unemployment assistance, and crisis counseling. Here again, 
exceptions may be made if the President determines that additional assistance is necessary to “to 
save lives, protect property and public health and safety, and lessen or avert the threat of a 
catastrophe.” 

b. Public Health Service Act 

The Secretary of HHS is authorized under the Public Health Service Act, 42 United States Code 
(U.S.C.) 201, et seq., to declare a state of public health emergency. This declaration enables 
HHS to delegate its granted authority, release funds and resources to prevent the proliferation of 
a communicable disease, and to plan an emergency medical response in the event of a disease 
outbreak. HHS is authorized to manage investigative and pnotective efforts, enter into contracts, 
assemble grants, disseminate information, and coordinate all other related actions reasonably 
necessary to respond to the emergency. The Act gives HHS and its delegated authorities, such as 
the Centers for Disease Control and Prevention and the Food and Drug Administration, wide 
discretion and independence in the management of such efforts. 

A federal declaration by HHS allows for the release of federal resources, including both money 
and manpower. During the FSE, as a result of the Declaration of a Public Health Emergency in 
Illinois and in the absence of a Presidential Declaration of an Emergency or Major Disaster there 
at that time, HHS enabled the activation of several DHS response assets, including the Disaster 
Medical Assistance Teams (DMATs) and Disaster Mortuary Operational Response Teams 
(DMORTs), 

c. State and local proclamations 

State and local authorities under conditions of disaster and emergency vary by state and locality. 
Authorities for the jurisdictions that participated in the FSE are summarized here for context in 
understanding how various declarations unfolded. 

State of Washington 

In Washington, the Governor may declare a state of emergency pursuant to the Revised Code of 
Washington (RCW) 43.06.220. Through a “Proclamation by the Governor” the Governor is 
authorized to create curfews and curtail public gatherings; control the manufacture, transfer or 


Section 503 of the Robert T. Stafford Di.saster Relief and Emergency Assistance Act, As Amended, 42 U.S.C. 
5121. 


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possession of flammables and explosives; prohibit the possession of firearms except within a 
personal residence or business; designate the dispensing of alcohol as illegal and subject other 
goods to similar control measures; determine the use and closures of roads and highways; and 
anything else the governor reasonably believes to be for the safety and welfare of the residents of 
the State. During the FSE, the Washington Governor authorized the Washington Emergency 
Management Division to establish food control areas around suspected areas, and for others to 
issue embargoes and perform sp>ecific kinds of inspections. In addition, the proclamation 
activated the National Guard. 

The Emergency Management Assistance Compact Act as codified in Washington State RCW 
38.10.010 et seq., provides mutual a-ssistance between states entered into the compact in 
managing any emergency or disaster declared by the governor of the affected state. The 
philosophy behind this compact is that few disasters remain within the neat confines of 
jurisdictional borders, and that many states have unique resources they can contribute to a 
neighboring, compromised state in the event of an emergency. This Act e.stablishes the rules for 
such mutual cooperation in emergency-related activities. 

A county may, and in the event of a Presidential Declaration must, issue a local proclamation of 
emergency. During the FSE, King County released a proclamation on May 12, 2003 at 1351 
PDT pursuant to RCW 38.52 and King County Charter (K.C.C.) Chapter 12.52, stating that due 
to an explosion, the presence of radiation and other related hazards, additional steps had to be 
taken to protect the life and prop)erty of the county’s citizens. This authorized the designated 
departments of King County to enter into contracts and incur obligations necessary to combat the 
emergency at hand. 

Finally, the Mayor of Seattle may declare a civil emergency through a local proclamation of civil 
emergency order and did so during the FSE on May 12, 2003, immediately after the explosion, in 
accordance with the Seattle Municipal Code, Chapter 10.02, the Charter of the City of Seattle, 
Article V, Section 2, and RCW Chapter 38.52. It. too, serves the purpose of releasing funds and 
delegating authority in an emergency situation. During the FSE. the proclamation delegated 
authority to city department heads (e.g., the police chief) so that the Mayor could coordinate the 
overall response effort. Additionally, the proclamation notified the public of conditions where 
the exercise of certain rights may be curtailed, but only to the extent that the conditions make it 
necessary. A copy of the order was both made public and delivered to the governor of 
Washington and to the King County executive. 

State of Illinois 

28 

Ehirsuant to the Illioois Emergency Management Agency Act , Chapter 20 of the Illinois 
Compiled Statutes, section 3305/7 {20 ILCS 3305/ 7), the Governor may declare by 
proclamation that a disaster exists. Disaster means, in relevant part: 

...an occurrence or threat of widespread or severe damage, injury or loss of life 
or property resulting from any natural or technological cause, including but not 
limited to explosion, riot, hostile military or paramilitary action, or acts of 
domestic terrorism ” (20 ILCS 3305/4). 


28 


Illinois ratified the Emergency Management Assistance Compact Act and codified it as 45 ILCS 151/5 (2203). 


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The Governor proclaimed a state of emergency for the greater Chicago area on May 13. 2003, at 
1230 CDT. Upon such a proclamation, the Governor may exercise designated emergency 
powers for 30 days. Among the.se emergency powers are the abilities to suspend provisions of 
any regulatory statutes or procedures for .state business; to utilize all available state resources; to 
transfer the direction, personnel, or function of state departments facilitating disaster response; to 
take possession of personal property; to recommend evacuation, and so on. The proclamation of 
disaster also activates the state emergency operations plan. 


An Illinois county may declare a local disaster as determined by 20 ILCS 3305/11. A 
declaration may only be made by a principal executive officer of a political subdivision (i.e., a 
county) or by hi.s/her interim emergency successor and cannot be continued to excess of seven 
days except with the consent of the governing board of the political subdivision. The effect of the 
declaration of a local disa,ster is to activate the emergency operations plan of ftat political 
subdivision and to authorize the furnishing of aid and assistance. The TlUfiois data indicated that 
four Illinois counties declared a local disaster at one point or anoth^ and decided to consolidate 
the announcement of the declarations into one. 

3. Recon.structlon 

Figure 6 depicts the timeline of the vimous proclamations and declaraftons of emergency and 
disaster that occurred during the FSE. 


Proclamations and Declarations 



Figure 6. Proclamations and Declarations 


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a. Washington venue (all times PaciHc Daylight Time) 

In Washington State, local authorities initiated proclamations of civil emergency immediately 
after the explosion which occurred just after noon PDT on May 12, 2003. A primary purpose of 
the local proclamations was to bring in resources from outside the city and county, above and 
beyond those accessible through existing mutual aid agreements with emergency services 
departments in neighboring jurisdictions. 

Shortly thereafter, the governor signed a proclamation declaring a state of emergency in western 
Washington, authorizing the e.stablishment of food control areas and food embavgcws by the 
Washington State Department of Health and Agriculture. The State Emergency Operations 
Center (EOC) received a copy of the proclamation at 1432 PDT, and it was forwarded to the 
Joint Operations Center by 1446 PDT. 

The WA Governor signed a request for a declaration of major disaster under authorities of the 
Stafford Act at 1620 PDT on May 12, 2003. This reque.st was received by the White House at 
2330 EDT, and signed by the President (notional) at 0900 EDT on May 13, 2003. 

b. Illinois venue (all times Central Daylight Time) 

In contrast to the explosion in Washington, the disaster unfolded silently in Illinois. Cases of a 
mysterious respiratory illness first appeared on May 12, 2003. The first awareness of a potential 
pattern was observed around 1730 CDT on May 12 when the Pro-Net surveillance system^^ 
noted a cluster of respiratory cases at Edward Hospital in DuPage County. The illness was 
presumptively diagnosed as Pneumonic Plague on the morning of May 13 as cases began to 
mount, and a bioterrorism attack was suspected. Illinois Operational Headquarters and 
Notification Office soon thereafter activated Phase I of the Public Health Emergency Plan. 

Just after noon CDT on May 13. 2003, the Chicago Director of the Office of Emergency 
Management (OEM) recommended a declaraticMi for a state of emergency in Chicago, which 
authorized the city to take necessary actions, such as ordering people to shelter-in-place. 
Meanwhile. Cook, DuPage, Kane, and Lake Counties (the “collar” counties surrounding the City 
of Chicago) were initiating county-level declarations of emergency as well, and, together with 
FEMA, discussed whether to issue a joint declaration of disaster. The collar counties agreed that 
news of the county declarations should be announced jointly. At about the same time the IL 
Governor signed the Proclamation of a State of Emergency for Illinois. There was some 
question as to whether this proclamation made local proclamations of emergency moot, though 
they ultimately realized that local declarations were required to initiate local emergency 
authorities. A joint Chicago/Cook County Declaration of Emergency was signed at 1500 CDT 
and the Chicago OEM issued a news release announcing a stale of emergency due to Pneumonic 
Plague at 1510 CDT. 

At 1730 EDT on May 13, 2003, after consultations with Illinois officials and confirmation that 
the disease was Pneumonic Plague, the HHS Secretary declared a Public Health Emergency for 
Illinois. Meanwhile, the IL Governor sent a request for a Declaration of Major Disaster under 
the authorities of the Stafford Act to the President through FEMA Region V at 1 700 CDT. Upon 


The Pro-Net surveillance system collects syndromic information from hospitals in DuPage County using a Web- 
based interface. The data are evaluated by software to determine if there are any unusual clusters or trends 
occurring. If an unusual spike in cases is detected the system alerts the kx:al public health responders via a pager 
system. 


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receipt of the IL Governor’s request for a Presidential Declaration of Major Disaster, FEMA 
Region V advised: “Although the Governor requested a major disaster declaration, under the 
Stafford Act definitions, an emergency declaration is FEMA’s most appropriate immediate 
action.” Accordingly, FEMA recommended that the President (notional) issue an emergency 
declaration, with “Individual Households Program and Categories A and B under Public 
Assistance [being] made available in the following jurisdictions: Cook (including City of 
Chicago), DuPage, Kane, and Lake Counties.” A Presidential Declaration of Emergency was 
approved at 1105 EDT on May 14, 2003. There was some confusion among participants as to 
whether the request for a Declaration of Major Disaster was approved, but it was not. 

4. Artificialities 

The FSE artificialities did not substantively impact participant play or the cbncfasions in this 
topic area. 

5. Analysis 

The declaration of the public health emergency in the Chicago area was enacted with little 
confusion or difficulty in execution. However, it appeared that the state and local declaration 
processes in Illinois were at times confused. Members of the Illinois Emergency Management 
Agency and Illinois Department of Public Health for example, discussed whether a county-level 
declaration needed to be enacted in light of a stale declaration of emergency, and there was some 
confusion among the collar counties as to the status of the different jurisdictions’ declarations at 
various points in time. Also, there was some confusion in the Illinois State EOC as to whether 
the request for a Presidential Declaration of Major Disaster under the Stafford Act had been 
approved, which it had not — a Declaration of Emergency was approved. 

Furthermore, although the process of obtaining a Presidential Disaster Declaration went 
smoothly in Washington, it was not as smooth in Illinois. Officials in Illinois requested a major 
disaster declaration to obtain maximum Federal assistance for the growing bioterrorism disaster, 
out of concern for the perceived five million dollar limit and other limits to Federal assistance in 
declarations of emergency. Some were unaware that the President can approve an expenditure of 
funds and approve services in excess of these limits under the conditions described above. For 
example, Illinois participants were not sure if the declaration authorized the Substance Abuse 
and Mental Health Services Administration (SAMHSA)/FEMA crisis counseling program. The 
FSE did not play out long enough to trigger the need for assistance in excess of those services 
allowed, or to allow for the Federal government to determine whether funds could be spent on 
programs not specifically named under Emergency Declarations of the Stafford Act, 

It is interesting to note that the outbreak of plague in Illinois did not qualify as a major disaster 
by definition in the Stafford Act; biological disasters are not referenced in the Act. It is not clear 
from the FSE whether the difference in declaring an emergency or a major disaster would result 
in substantive real-world issues given the exception clauses under declarations of emergency 
described above. 


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6. Conclusions 

Both of the simulated terrorist attacks in the 
FSE led to local declarations of emergency 
by multiple affected jurisdictions. The 
bioterrorism attack in Illinois was especially 
challenging in this arena with a widespread 
impact involving multiple counties, the City 
of Chicago and the State of Illinois. 

Since there is no real-world precedent in 
which the Stafford Act has been applied to a 
biological disaster — or one involving non- 
explosive radiological, chemical. or 
biological weapons — it is noteworthy that 
during the FSE, the large-scale bioterrorism 
attack did not qualify as a major disaster. 

Future efforts, including exercises, should 
continue to refine the applicability of the 
Stafford Act to bioterrorism and other non-explosive disasters not explicitly defined by the Act, 
to increase Federal, State, and local (FSL) agency familiarity with its application to, and 
implications for, such disasters. 

Finally, while the FSE did not necessarily indicate confusion with activation of the Fhiblic Health 
Act, or the declaration by HHS of a Public Health Emergency; the relationship between these 
authorities (and the resources that are brought to bear under them) and those available through 
the Stafford Act should continue to be exercised for maximum clarity at all levels of government. 



Summary of Conclu.sions — 
Declarations: 


In Washington, the proclamation and declaration 
processes went smoothly during the FSE. In Illinois, 
however, there was more confusion. 

Future efforts should continue to explore the 
applicability of the Stafford Act to biological and 
other non-explosive terrorist emergencies that do not 
qualify as a major disaster, as currently defined by 
the Act. 

While there was little confusion regarding the 
activation of the Public Health Act. the relationship 
between it and the Stafford Act, especially the 
authorities and resources that are brought to bear 
under them, should continue to be exercised. 


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54 



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C. Department of Homeland Security Play in T2: The Role of the Principle Federal 
Official 


1. Introduction 

The Top Officials (TOPOFF) 2 (T2) Full-Scale Exercise (FSE) was the first opportunity for the 
newly created Department of Homeland Security (DHS) to exercise and experiment with its 
organization, functions, and assets. Figure 7 depicts the organization of DHS. 


Department of Homeland Security 



(i): Kffetlivf March iM.f 


Figure 7. Organization of the U.S. Department of Homeland Security 

Table 4 lists those DHS directorates, offices, and agencies for which the analysis team has data 
documenting their activities in the FSE. Table 4 includes, when available, a summary of the FSE 
activities of these organizations and the assets they deployed during the exercise. It is important 
to note that other DHS organizations, such the Office of Emergency Response, played important 
roles in the FSE, but data collectors were not present at their Emergency Operations Centers or 
Headquarters. 

A number of DHS emergency response assets were set up or deployed for the first time during 
the FSE. These include new entities that report directly to the DHS Secretary: the Crisis Action 
Team (CAT) and the Principle Federal Official (PFO). 

During the FSE, the CAT reported to the DHS Secretary or Chief of Staff. The CAT was the 
Secretary’s assessment and advisory team, providing the information and recommendations 
needed to make decisions and advise the President. In addition to the DHS directorates, offices. 


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and agencies listed in Table 4 that had representatives in the CAT, liaisons from the White 
House, Federal Bureau of Investigation (FBI), Environmental Protection Agency, and Nuclear 
Regulatory Commission were also stationed in the CAT. The Department of Health and Human 
Services (HHS) and Department of Energy (DOE) liaisons were in the DHS Homeland Security 
Center across the hall rather than in the CAT.^ This is surprising given that DOE was the lead 
technical agency for the radiological response in Washington and HHS was the lead technical 
agency for the public health response in Illinois.^' 

The DHS Secretary designated PFOs and deployed them to the Washington and Illinois venues. 
The PFO’s role in emergency response was first implemented during T2, and is now being 
codified by DHS. Based upon PFO activities during the FSE, the PFO will serve a pivotal role in 
the response capabilities of DHS. To further support the efforts of DHS to define the roles and 
responsibilities of the PFO, this section focuses on the PFO activities, interactions, and lessons 
learned from the FSE. Because it is focused on the activities of individuals as opposed to 
organizations, the reconstruction presented in this section is much briefer than that presented in 
other sections. It is important to note that the analysis team had an analyst with the Seattle PFO 
allowing for a fairly detailed reconstruction of the PFO’s interactitms and activities. The 
reconstruction and observations for the Illinois PFO are based upwi information from data 
collectors, and as a result, a detailed timeline for the PFO activltie.s in the Illinois venue was not 
developed. 



HHS had personnel limitations during this exercise due to real-world commitments, including Severe Acute 
Respiratory Syndrome (SARS). This resulted in a choice to staff the Homeland Security Center full-time, but 
meant they did not have representation in the Crisis Action Team (CAT). 

'' For additional information about the CAT, see the Stanford Report in Annex B. 


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Table 4. Directorates, Offices, and Agencies within the Department of Homeland Security That 
Played in T2^^ 


Dikectorate/Office/ 

Agency 

Activities/Assets Deployed 

Border and Transportation 

Security (BTS) Directorate 

• Bureau of Cuslom-s and Border Protection (CBP) activated the 
CBP Command Center 

• The Transportation Security Administration activated its 

Crisis Action Center jk 

• Immigration and Customs Enforcement/Federal Protective'^k 

Services activated its Communications Center, Situation ^ 

Room Ik 

• Participated on Crisis Action Team (CAT) i 

Emergency Preparedne.ss and 
Response (EPR) Directorate 

• Activated the National Interagency Emergency Operati^g^ 
Center. Emergency Support Team at EPR'toadquarterMf^^ 

• Deployed assets including Domestic Emergenqf^myort 

Team, Federal Coordinating Officers, ^Mobile Efl^ency 
Response System, National Disa^r Mewal Systom, 

Strategic National Stockpile.'-and lM>an ^rch and^Rescuc 
Incident Support Teams \ y 

• Panicipated on CAT /X 

Science & Technology Directorate 

• Participated on CAT \ 

Information Analysis and 
Infrastructure Protection 
Directorate 

'~<X- ' 

U.S. Coast Guard 

• Activated Crisis^Soion Center 

• I^Siuipated on CAH^ 

U.S. Secret Service 

• /feti^feSlBkector’S Crisis Action Center 

OIBce of International Affairs 

• Pahicipated OffCAT 

Office of Legislative Affairs 

• Paiitcipated on CAT 

Office of Public Affairs 

• Participated on CAT 

Office of State and Local \ 

Government Coordination \ 

^j^^^rtiJ^ated on CAT 

Office of National Capital Regicni^ 
Coordination \ 

• Participated on CAT 

General CouBMOk ^ 

• Participated on CAT 

Private Sec&r 

• Participated on CAT 



The offices and agencies in this table represent only those for which the analysis team has data. 


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2. Background 

The concept of a PFO is laid out in Homeland Security Presidential Directive (HSPD)-5: “the 
DHS Secretary is named as the PFO for the management of terrorist attacks, major disasters, and 
other emergencies in the United States”^’^. 

The duties and responsibilities of the PFO are further elaborated upon in the draft National 
Response Plan (NRP):^ 

Principle Federal Official. The Federal official responsible for directing 
Federal operations in the United States to prepare for, respond to, and 
recover from domestic incidents; for directing the application of Federal 
resources in specific circumstances; and for managing any domestic 
incident when directed by the President.^^ 

The draft NRP continues, stating that the DHS Secretary can name a senicw Federal official as 
the Secretary’s senior representative at the incident. This person overaees the federal response in 
the field. The responsibilities of the Secretary’s representative include: 

• Coordinating and synchronizing the activities of primary Federal agencies and supporting 
agencies; 

• Overseeing the allocation of resources for response and recovery; 

• Coordinating the release and di.stributi(» of information; and 

• Communicating with the Secretary.'^^ 

The draft NRP gives the Secretary’s re|M«sentative scttue authorities that traditionally were tho.se 
of the Federal Coordinating Officer (FCO) and the FBI Special-Agent in Charp (SAC) under 
the existing FRP and U.S. Government concept of operations plan (CONPLAN)''. 

3. Reconstruction 

a, Washington venue (all times are Pacific Daylight Time ) 

Mike Byrne, the DHS Director of National Capital Region Coordination for Emergency 
Response, was appointed the PFO in Washington. Figure 8 lays out a reconstructed timeline of 
his activities in the Washington venue. He notionally deployed with the Domestic Emergency 
Support Team (DEST), prior to the radiological dispersal device (RDD) explosion in Seattle, in 
response to exercise intelligence citing a possible terrorist attack at the Columbia 


35 


Homeland Security Presidential Directive/HSPD-5, February 28, 2003. 
T2 did not exercise the draft National Response Plan. 

United States Government National Response Plan (draft) 
http://www.nemaweb.org/docs/NalionaLResponse_Plan.pdf 
'Mbid. 

Ibid. 


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Generating Station near Richland, Washington.^* Mr. Byrne was notified of the proposed 
diversion of the DEST from Richland to Seattle on May 12, 2003, at 1235, and he arrived at the 
Joint Operations Center (JOC) in the FBI Field Office in Seattle at approximately 1700. At the 
JOC, he worked closely with the Federal Emergency Management Agency (FEMA) Region X 
Director, senior DOE officials, and the FBI SAC. 


Upon arrival, Mr. Byrne established a unified command where all Federal agencies with 
jurisdictional authorities contributed to the process of determining overall incident objectives, 
selecting strategies, ensuring integrated operations, and maximizing use of all resources. To 
ensure that the federal response was coordinated and that action plans were consolidated, Mr. 
Byrne led regular briefings with his Command Group, consisting of the DEST and liaisons from 
key Federal, State, and local jurisdictions and agencies. These briefings focused on the status of 
the response, assets deployed, consensus building, and the development of recommendations to 
present to the State and local authorities. 

Mr. Byrne also directed that all federal communications would be integrated .so that there was 
one consistent voice speaking for the Federal Government. In addition, he woriced to ensure that 
the integrated federal communications was consistent with communications coming from the 
State and local authorities. He instructed the FBI JOC to be more forthcoming with information 
to both State and local authorities and with the JOC Consequence Management Group (CMG). 
Mr. Byrne also initiated and led regular conference calls with top officials (or their 
representatives) from Seattle, King County, Washington State, and FEMA. In these conference 
calls, he discussed current federal support, offered recommendations, responded to questions 
concerning issues raised by the State, county, and city officials, and tried to assure Seattle, King 
County, and Washington State officials that they had the same information that he had. 

He was also concerned about the apparent lack of integrated communications prior to his arrival 
between the Joint Information Center (JIC) and DHS and took steps to rectify the problem. For 
example, he discovered that DHS had raised the threat level to Red in seven cities, closed roads 
and airports, placed restrictions at border crossings without a message ever coming to the 
Washington JIC or JOC. To rectify the situation, he instructed the JIC to provide a liaison to the 
JOC CMG and to communicate more^regularly with DHS. 

Mr. Byrne also kept in touch with DHS Headquarters through regular conversations with the 
DHS CAT;^^ V 


From the U.S. Government Inter-agency Dome.slic Terrorism Concept of Operations Plan: “The DEST is a rapidly 
deployable, inter-agency team responsible for providing the FBI expert advice and supptrrt concerning the U.S. 
Government’s capabilities in resolving the terrorist threat or incident. This includes crisis and consequence 
management assistance, technical or scientific advice and contingency planning guidance tailored to situations 
involving chemical, biological, or nuclear/radiological weapons.” Note that the DEST is now a DHS-managed asset 
that supports the Lead Federal Agency during a terrorist threat or incident. 


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* 1208: Explosion 

' 1800: PFO Command Group briefing 
* 1830: PFO briefs DHS CAT (apfvoximate) 

* 1930: Public Information briefing 

* 2000: PFO tele-conference wilb Seattle. King County. WA State, & FEMA top officials 
* 2200: PFO Conunand Croup briefing 

' 2300; PFO Command Group briefed by FRMAC Director 
2300-0700: JOC CLOSED 

' 0800: PFO approves release of FRMAC maps at morning 
command brief 

* 1000: PFO tele-conference with Seattle. King County, 

WA State. & FEMA lop officials 
* 1130: Press Conference wilb PFO. FBI SAC, Seattle 

Mayor. King County Executive, WA Slue Patrol. 
FEMA Region X Director. & Seattle/KC Public 
1220: Ad-hoe meeting between FRMAC Director. PFO. * Health Director 
Seattle Mayor. & Seatile/KC Public Health Director 

1330; PFO briefs Principles Committee * 

1500: PFO tele-conference with Seattle, King • 

County. WA Stale. & FEMA Cop officials 

1800: PFO Command Group briefing •> 

2300-0700: JOC CLOSED 

0900 ; PFO Command Group briefing * 

1000: PFO lele-confercncc with Seaule. King County. WA Stale, & FEMA lop officials • 

— 1100: PFfVCommand Group hoiwash * 

1330: PFO visited WA State EQC • 

n 1 1 1 1 I — n 1 1 ^ 1 — 

1200 1600 2000 0000 0400 0800 1200 1600 2000 0000 0400 0800 1200 

12 May 131^ 14 May 


Figure 8. Outline of Principle FederttI Official Key Events in Washington State (all times are 
Pacific Daylight Time) 

b. Illinois 

Wayne Pareni, ihe Operations Coordinator for the Border and Transportation Security 
Directorate in DHS. was appointed the PFO in Illinois. In the Illinois venue, the PFO spent Ihe 
first two days in the FEMA Regional Operations Center (ROC) and moved to the JOC when it 
stood up on May 14, 2003. At the ROC, he worked clo.sely with the FEMA Region V Director. 
At the JOC. he worked with the Region Director (RD), the SAC, and the FCO. 

As PFO. Mr. Parent ensured that communications were integrated, action planning between the 
SAC and the RD was coordinated, and that State and local officials that were actively involved. 
His approach was to foster consensus among the jurisdictions and agencies. To that end, a series 
of regularly scheduled teleconferences was held with Federal, State, and local (FSL) agencies. 
These calls featured briefings, coordination, de-confliction. and decision-making. Typically. Mr. 
Parent did not have to adjudicate among agencies; the teleconferences and follow-up discussions 
resulted in decisions reached through consensus. 

Mr. Parent kept in touch with DHS headquarters through regular morning and evening 
conversations with the CAT leader. He also contacted the CAT leader when issues arose, with a 
total of four or five contacts per day. He provided an encapsulated situation report to the CAT 
during the evening conversation. 


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4. Artificialities 

By design and consistent with the open book nature of the FSE, the PFO arrived in Chicago a 
week before the exercise and met in advance with many of the officials involved. In fact, HHS 
provided the PFO with a subject matter expert (SME) before he was officially appointed PFO. 
In addition, both PFOs had advance knowledge of the scenario. Thus, they had more situational 
awareness of the specific players and of the situations they would each be facing than a typical 
PFO would likely have in an actual incident. This is not a criticism of the PFOs; in fact, it likely 
enhanced the learning opportunity for DHS and all FSL agencies involved. 

5. Analysis 

a. The relationship between DHS and FEMA 

The relationship between the PFO and the FEMA officials was different in the two venues. In 
Washington, Mr. Byrne’s activities were consistent with his concept for the PFO role. This 
concept involved the development of a Command Cell, consisting of the PFO, FCO, FBI SAC, 
and State and local counterparts for the response phase of an incident. As envisioned, the PFO 
would prioritize and adjudicate between the often-competing needs of the crisis and consequence 
management sides of the response phase. This allowed the FBI SAC and the FCO to concentrate 
completely on their respective aspects of the response. Under this concept, the PFO truly 
became the one voice for the federal response. Mr. Byrne’s view of the PFO role was clearly 
observed during the FSE. As PFO, he quickly instituted a unified command to manage the 
overall federal response and coordinate integrated communications and action planning, but left 
the FBI SAC to coordinate the crisis response, and left the FEMA RD and the FCO to coordinate 
the day-to-day activities of the federal consequence management assets. 

It is important to remember that in Washington, although an RDD device was involved, the event 
unfolded in more of a traditional first responder fashion with a relatively well-delineated disaster 
site'^^. With the rapid discovery of radiation, federal assets quickly came into the exercise picture 
and, importantly, a JOC was quickly established. In Illinois, events unfolded more gradually as 
would be expected during a disea.se outbreak. There were no clearly defined disaster sites 
(although release sites were eventually identified) and the JOC stood up a couple of days into the 
event. Mr. Parent worked within the framework of a unified command to ensure that integrated 
communications were achieved and that action plans were coordinated, but did so in a less overt 
manner than Mr. Byrne. 

The different approaches to the role of the PFO suggest that DHS should take this opportunity to 
clearly de-conflict and define the responsibilities of the PFO with respect to the FEMA RD and 
FCO in the final NRP. The relationship may differ depending on the circumstances, but general 
guidelines need to be formulated and implemented. In addition, the PFO roles and 
responsibilities defined in the draft NRP may or may not be appropriate during the recovery 
phase of disasters. Since the recovery pha.se was not examined in much detail during the FSE, 
further exercises will be needed to shed some light on this issue. 


The uncertainties that responders faced al the RDD incident site are discussed in detail in the Special Topics 
sections: “Data Collection and Coordination: RDD Plume Modeling and Deposition Assessment" and “Balancing 
the Safety of First Responders and the Rescue of Victims.” 


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b. PFO Resources 

During the FSE, both PFOs required additional technical support beyond their administrative and 
security details to accomplish their respective roles and responsibilities. In Washington, Mr. 
Byrne used the DEST and, in some cases, the JOC CMG to support his efforts. He informed the 
evaluation team that the DEST has the capability to support the PFO, FCO, and FBI SAC during 
the response pha.se of an emergency if they are all co-located as a Command Cell. This has the 
added benefit of reducing redundancy, as Emergency Support Function personnel would not be 
needed to staff both the JOC CMG and the FEMA ROC. 

In Illinois, Mr. Parent was provided with an SME from HHS after a meeting with the head of the 
HHS Secretary’s Emergency Response Team (SERT). Mr. Parent reported to the evaluation 
team that this support was essential to helping him understand the specifics of the bioterrorism 
event and the critical role that HHS would play in a real-world event. 

6. Conclusion 

The FSE presented DHS with an excellent 
opportunity to evaluate and exercise 
emergency response procedures, teams, and 
assets. During the FSE, both PFOs 
encouraged and facilitated integrated 
communications and coordinated action 
planning. They also both encouraged active 
communication with State and local 
authorities. While their leadership styles may 
have differed, the roles that each had 
during the FSE may have also reflected, to a 
degree, differences in the problems that each 
encountered and that the terrorist attacks 
developed differently in the two venues. 

While the concept of the PFO was well-received, the roles and responsibilities of the PFO 
compared to those of the FEMA RD, the FEMA FCO, and the FBI SAC still need to be clarified. 
In addition, the PFO requires a staff with the flexibility and expertise to support all emergencies, 
natural and terTwist-related. If the DEST is expected to support the PFO and the Federal 
response, DHS should consider providing enough resources to staff at least one additional team 
in the event that more than one federal emergency occurs at the same time, as was exercised in 
the T2 FSE. 


Summary of Conclusions — 
PFO; 


The PFO was well received by Federal. Stale, and local 
authorities during the T2 FSE. 

The roles and responsibilities of the PFO vice the 
FEMA FCO. FEMA Region Director, and FBI SAC 
need to be further clarified in the final National 
Rcspon.se Plan. 

The PFO requires a dedicated staff with the flexibility 
and expertise to support all emergencies. 


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D. Data Collection and Coordination: Radiological Dispersal Device Plume Modeling and 
Deposition Assessment In Washington 


1. Introduction 

During the Top Officials (TOPOFF) 2 (T2) 

Full-Scale Exercise (FSE), designers 
simulated the explosion of a radiological 
dispersal device (RDD) in Seattle, 

Washington. In the aftermath of an RDD 
explosion, the development of analysis 
products, including plume prediction models 
and radiological deposition maps, which 
show the potential impact of the radiation on 
people, agriculture, and the environment, is 
vital. These maps provide policy-makers 
and top officials with the information they need to make effective decisions. 

In the initial hours following an RDD explosion, radiation experts rely on predictive plume 
models to give decision-makers a rough sense of how current weather conditions affect where 
the radioactive materials are likely to spread. As responders learn more information about the 
explosion — such as an estimate of the amount of explosives and the lype(s) of radiological 
material used — additional data can be entered into the predictive plume models. Model outputs 
can then be u.sed to update the prediction maps. During the FSE. different agencies and 
jurisdictions used one or more plume models to generate predictions, which led to both 
confusion and frustration among top officials in Washington State and Washington, D.C. 

As the response progresses and empirical data are collected in the field, deposition or “footprint” 
data products are developed. For these products to be useful to decision-makers, subject matter 
experts (SMEs) must first interpret the data to determine the impact on people, agriculture, and 
the environment using Environmental Protection Agency (EPA) Protective Action Guidelines 
(PAG).-"' 

All radiological data collected by Federal. State, and local (FSL) agencies should be coordinated 
so that SMEs can develop the most up-to-date data products, and lop officials in different 
locations have consistent information upon which to base their decisions. For Federal agencies, 
the Federal Radiological Emergency Response Plan (FRERP)-*' assigns data coordination to the 
Federal Radiological Monitoring and Assessment Center (FRMAC). During the T2 FSE, 
however, coordinating data collection proved to be a significant challenge. As a result, FSL 
agencies that developed data products and deposition maps used different and incomplete data. 
A further challenge during the FSE was the distribution of the many data products generated 
throughout the exercise. In addition, confusion was apparent over the differences between maps 



EPA is assigned the responsibility for developing Protective Action Guidelines (PAGs) under various authorities, 
including the Radiological Emergency Planning and Preparedness Regulation (44 CFR S.*! I ). EPA coordinates the 
interagency development of the PAGs through a subcommittee of the Federal Radiological Preparedness 
Coordinating Committee. 

The Federal Radiological Emergency Response Plan (FRERP) {50 FR 46542). of 11-8-85. revised 1996. 


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generated from predictive plume models vice empirical data products and deposition maps. The 
impact on top officials was delayed decision-making or, in some cases, policy decisions that 
were made under conditions of uncertainty. Although decision-making under rapidly changing 
and ambiguous situations is always part of emergency response, overcoming the data 
coordination and analysis product distribution challenges can reduce the uncertainty observed 
during the FSE. 


Two critical issues had a significant impact on the response observed during the T2 FSE: 

• Coordinating the data collected by multiple agencies at FSL levels of government; and 

• Developing and distributing analysis products — including plume model prediction 
overlays and empirical deposition, footprint maps — to subject matter experts (SMEs) and 
decision-makers by multiple FSL agencies. 

In real emergencies and during the FSE, these two Issues interact to impact decision-makers. 
Figure 9 shows what might be considered an ideal picture of the data collection, coordination, 
and product distribution process. Under most circumstances, data collection will take place in 
multiple locations and involve multiple agencies. The challenge is for all of these agencies to 
coordinate their data collection efforts and send all of the data to an agreed upon clearinghouse 
where it is interpreted, entered into a prediction model or developed into deposition maps, and 
then provided to SMEs and decision-makers. Again, for Federal agencies, this is the 
responsibility of the FRMAC as described in the FRERP. 

However, if FSL agencies send their raw data to different locations, rather than a centralized 
location, and there is no coordination among the different agencies, then analysis will not be 
conducted with the complete data set. If the analysis and the resulting analysis products are not 
consistent, then top officials and poli^makcrs will have differing, and potentially conflicting, 
information. Such conflicts will impac^t officials’ ability to develop consistent and agreed upon 
decisions. Follow-on legal implications^^and negative public perception are also potential results 
of a poorly-coordinated Fg^ response. \ 



64 



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Figure 9. An Ideal Picture of the Data ColtStion, Coordination, Interpretation, and 
Dissemination Process ^ 


This special topic begins with a discussion of the FSL agencies and departments that have 
responsibilities or authorities under current FSL codes and inter-agency agreements to collect 
and coordinate radiological data; conduct analyses; and provide models, maps, and other analytic 
products in radiological emergencies. This background information is followed by a 
reconstruction of the events that occurred during the FSE and an analysis of the reconstruction. 
Finally, the last section contains conclusions based upon the analysis of the FSE and the existing 
codes and authorities. 

2. Background 

In the aftermath of an explosion containing radioactive materials, the detection of radioactivity 
will lead to a number of agencies being called to the scene. Some states, including Washington, 
have robust radiological incident management capabilities, and. therefore, provide State-owned 
assets to the incident. In addition, they can draw upon Federal assets from the Department of 
Energy (DOE). Environmental FTotection Agency (EPA), Department of Health and Human 
Services (HHS). United States Department of Agriculture (USDA), the Nuclear Regulatory 
Commission (NRC), and others to augment their efforts. 

Although capabilities for radiological detection across the United States and territories vary, the 
issues that arose during T2 are likely too generalized for many localities across the country. 
Therefore, it is useful to understand Seattle and Washington radiological detection capabilities 
and how their terrorism response plans are designed to integrate resources to create a unified 


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response. A discussion of the primary federal assets that have radiological response capabilities, 
focusing on agencies and departments that participated in T2, is also included.^ 

a. City and state response capabilities 
Seattle capabilities 



Seattle Fire Department (SFD) Hazardous Materials (HAZMAT) vehicles and equipment have 
dosimeters that detect radiation. SFD HAZMAT personnel are likely to be the fij^ radiation 
data collectors to arrive at a scene with suspected radioactive materials. 

Washington State capabilities 

• Washington State Department of Health'. 

In the Division of Environmental Health Programs, the WashingtoniState'^epartment Tf Health 
(DOH) maintains a Division of Radiation Protection. The division^clude^xpert handlers of 
radioactive materials and incident management. DOH field ieam\oor^mation is conducted from 
the Radiation Monitoring and Assessment Center (RMAC).'''^^^Mi^^has the capability to 
provide dose assessment for field teams, collect and coordinate radiological data, and develop 
protective action recommendations and sampling plans'”. \ 

In the event of a radiological incident, the Washington State DOH Public Health Laboratory 
supports the efforts of the Division of Radiation Protection to determine the immediate health 
risk to the public. The mission of the laboratory is to |Movide information to health officials as 
quickly as possible so that they have the data they n^d to assess the level of hazard to the public. 
The Radiation Chemistry Group rapidly performs radiological analyses to determine what 
radioactive materials are present in samples collected at an emergency site and can detect activity 
levels relevant to protective action guidelines'*^. 

• Washington State Department of Ecology: 

Under the Spill Response Section in the Spill Prevention, Preparedness, and Response Program, 
the Washington State Department of Ecology maintains the Ecology Spill Response Team. 
While DOH has the overall authority in Washington State for radiological incidents, the 
Department of Ecology is often called upon for assistance since the Ecology Spill Response 


The evaluation team is unaware of any King County radiological data collection teams or formal modeling 
capabilities at the King County EOC. 

There are nationwide efforts to increase the percentage of US jurisdictions with radiological detection capabilities. 
In July 2002, the U.S. Departments of Eneigy and Justice co-spon.sored the Homeland Defense Equipment Reuse 
program (HDER). HDER provides surplus instrumentation and equipment to State and local fire, police and other 
emergency agencies to enhance their domestic preparedness capabilities. In FY 2003, deliveries to the pilot 
program cities included shipments to Philadelphia. Washington DC, Chicago, Detroit, Houston. Los Angeles, and 
San Francisco. In June 2003. the program was scheduled to go nationwide allowing all US states, the District of 
Columbia, Puerto Rico and the four US Territories to participate in the program and receive equipment, training, and 

local long-term technical support. 

44 

Washington State Department of Health, Division of Radiation Protection Plan and Procedures for Responding to 

a Radiological Attack, DOH/DRP, March 2003. 

45 

Information obtained from personal communication with DOH Public Health Laboratory personnel. 


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T2 


Team carries radiological monitoring instrumentation in all of their HAZMAT response 


vehicles'*^. 

• National Guard Weapons of Mass Destruction-Civil Support Teams: 

The Civil Support Teams (CSTs) are congressionally-mandated units of the National Guard 
whose mission is to support State and local authorities at a domestic weapons of mass 
destruction (WMD) incident site. The CST supports civilian authorities by identifying WMD 
agents, advising for response measures, short- and long-term consequences, and facilitating the 
request of additional resources. The CST is a State-owned asset that can deploy without a 
Department of Defense (DOD) authorization. The Adjutant General can deploy the CST to 
support the state’s response or to support another state’s response if requested by that state's 
governor.'*^ 

The CSTs are equipped with military standard radiation detection equipment. The survey team 
is also equipped with a handheld gamma spectrometer that provides the capability to identify 
specific gamma-emitting isotopes. The CSTs also have the capability to deploy with a mobile 
analytical laboratory system (MALS) to conduct on-site radiological- isotope antdyses.'*** 


b. Federal response capabilities and assets 
Department of Energy 

The National Nuclear Security Administration {NNSJ\) administers the many DOE assets that 
can be activated to respond to a radiological incident. These include: 

• Radiological Assistance Program: 



In the event of a radiological incident, the Radiological Assistance Program (RAP) provides 
radiological assistance when requested by other Federal agencies, states, local, or tribal 
authorities. A request for a.ssistance normally comes first into one of eight DOE regional 
coordinating offices, specifically the Regional Response Coordinator (RRC). The initial 
response is typically a regional team of specifically trained personnel and resources that support 
the local authorities. The RRC has the authority to request one or more of the DOE assets (e.g.. 
Atmospheric Release Advisory Capability, Aerial Measuring System, FRMAC, Radiation 
Emergency Assistance Center/Training Site, and other RAP regions) to support the response and 
to facilitate coordination between the DOE assets and other responding agencies.'*^ 

• Federal Radiological Monitoring and Assessment Center: 

According to the FRERP,*’’’ DOE is responsible for setting up and coordinating a FRMAC during 
the crisis phase of any radiological incident. Specific procedures are used to collect, analyze, 
assess, and disseminate data products useful to decision-makers. The efforts of all FRMAC 


46 


Information obtained from personal communication with Washington Department of Ecology personnel. 


In Washington the commanding officer of the WMD-CST has the authority to self deploy his unit. 

This information was obtained from communication with LTC Thomas Hook, Army National Guard. Chief, Civil 
Support Team Program, National Guard Bureau Homeland Defense Division. 

Department of Energy, Radiological Assistance Program^ (DOE 55.30.3). Other information found at 
http;//www .doe. bnl.gov/RAP/rap. htm. 

The Federal Radiological Emergency Response Plan (FRERP) (50 FR 46542), of 1 1-8-85. revised 1996. 


67 



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members are coordinated through these procedures to maximize efficiency and minimize 
confusion in their advice to decision-makers. Without such a coordinated effort, conflicting data 
products and excessively technical information may complicate decision-making. Once the 
FRMAC is established, all activated Federal assets are incorporated, and State and local 
technical experts are invited to co-locate and provide support to the FRMAC. Following the 
emergency phase, at a mutually agreeable time corresponding to the requirements found in the 
FRERP. the NNSA will transfer the responsibility of coordinating the FRMAC to the EPA. 
However, the NNSA and other federal agencies continue to support and provide resources to the 
FRMAC.' 


.^1 


The FRERP also calls for the establishment of the Advisory Team for Environment. Food, and 
Health (Advisory Team, or A-Team), which, while not a DOE asset, is colocated with the 
FRMAC. The A-team includes representatives from multiple Federal agencies and departments, 
including the EPA. USDA. HHS. and other Federal agencies, as warranted by the circumstances 
of the emergency. The A-team's primary responsibility is to provide the lead Federal agency 
(LFA) with advice on environment, food, health, and safety is.sues that arise during and from the 
emergency. The A-team provides direct support to the LFA but does not have independent 
authority. - 

• Aniiospheric Release Advisory Capability: 

Through the Atmospheric Release Advi.sory Capability (ARAC) program the DOE maintains the 
National Atmospheric Release Advisory Center (NARAC) at Lawrence Livermore National 
Laboratory (LLNL). NARAC provides atmospheric plume modeling tools and services for 
chemical, biological, radiological, and nuclear airborne hazards (both gases and particles) using 
real-time access to worldwide meteorological observations and forecasts through redundant 
communications links to data provided by the National Oceanic and Atmospheric Administration 
(NOAA), the U.S. Navy, and the U.S. Air Force. NARAC supports the Nuclear Incident 
Response Teams, the regional RAP teams, the Aerial Measuring System (AMS), the FRMAC. 
DHS under a DOE-DHS Memorandum of Agreement, and 40 DOE and DOD on-line sites. 
NARAC operational support of five cities and 53 state and Federal organizations across the 
country has been .successfully tested under DHS and DOE support. NARAC can simulate 
downwind effects from a variety of .scenarios, including fires, radiation dispersal device 
explosion.s, HAZMAT spills, sprayers, nuclear power plant accidents, and nuclear detonations. 
The NARAC software tools include stand-alone local plume modeling tools for end user’s 
computers, and Web- iuid Internei-ba.sed software to reach-back to advanced modeling tools and 
expert analysis from the national center at LLNL. Initial automated, advanced 3-D predictions of 
plume exposure limits and protective action guidelines for emergency responders and managers 
are available in five to ten minutes. These can be followed immediately by more detailed 
analyses by 24/7 on-duty or on-call NARAC staff. NARAC continues to refine calculations as 
measurements are taken, until all airborne releases have stopped, and until the hazardous threats 
are mapped and impacts assessed. Model predictions included the 3-D and time-varying effects 
of weather and terrain. NARAC provides a simple Geographical Information System (GIS) for 
display of plume predictions with affected population counts and detailed maps, in addition to 


'' Department of Energy. FRMAC Operations Manual Emergency Phase, (DOE/NV 1 1718-080 tJC-707). May 
1997. Other information found at h(tn://ww w.n\.doe.gov7nroerains/frmac7dcfaull.]itm . 

The Federal Radiological Emergency Respon.se Plan (FRERP) (50 FR 46542). of 1 1-8-85. revised 1996. 


68 


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the ability to export plume predictions to other standard GIS systems. NARAC products can be 
distributed through a password-controlled and encrypted website, e-mail or fax. 

The Environmental Protection Agency 

The EPA responds to radiological incidents under both the National Oil & Hazardous Substances 
Pollution Contingency Plan (NCP) and the FRERP. EPA can serve as the LFA, or can support 
State and local governments and the lead Federal agency by: 

• Conducting environmental monitoring, sampling, and data analysis; 

• Assisting responders in ensuring protection of Health and Safety; 

• Assessing the national impact of any release on public health and the environment 
through the Agency’s Environmental Radiation Ambient Monittwing System; 

• Providing technical advice on containment and cleanup of the radiological contamination; 
and 


Assisting in site restoration and recovery. 


53 


\ 


EPA’s On-Scene Coordinators maintain emergency response readiness, including survey and 
sampling equipment, for chemical and radiological incidents. In addition to a region's response 
capability, EPA Headquarters can also deploy its Radiological Emergency Response Team 
(RERT) to the accident scene as part of its radiological response. EPA’s RERT provides 
additional specialized monitoring, sampling, and both mobile and fixed laboratory capabilities. 
As part of the A-Team, EPA’s RERT members can provide State and local authorities with 
advice on protecting local residents from exposure to elevated radiation levels. Once the FRERP 
is activated, EPA radiological assets are expected to integrate with the FRMAC.^'^'^^ 

c. Requesting federal assets 

State and local governments, as well as tribal governments and private organizations, can request 
support from a number of Federal assets to support their response and recovery efforts following 
an explosion that includes radioactive materials. For example, the EPA receives their authority 
to respond to any release of a hazardous substance from the National Oil and Hazardous 
Substance Pollution Contingency Plan (National Contingency Plan)*'^ and the Public Health 
Services Act, among others. The DOE has similar authority to respond to a radiological incident 
as outlined in DOE 5530.3^^ to be superceded by DOE O 151. lA.*" 


Envirooiuental Protection Agency. Radiological Emergency Response Plan, January 2000. More information 
found at http://www.epa.gov/radiation/rert/index.htm). 

EPA's regitMial responders provided support to the local Incident Command System during the FSE. In addition. 
EPA deployed the Advance Units of its RERT. However, given the limited timeframe of the exercise and limited 
funding, EPA did not deploy RERT members who would have realistically only been able to arrive at the incident 
scene as the exercise drew to a close. 

Information specific to the EPA RERT is found at http;//www .epa.gov/radiation/rert/rert.htm. 

Title 40 Code of Federal Regulation (CFR) 300, National Oil and Hazardous Substance Pollution Contingency 
Plan. 

Department of Energy, Radiological Assistance Program, (DOE 5530.3). Other information found at 
http://www.doe.bnl.gov/RAP/rap.him. 


58 


Department of Energy, Comprehensive Emergency Management System, (DOE 0 15 1.1 A). 


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In combining the responsibilities and authorities defined in the FRERP,^^ Concept of Operations 
plan (CONPLAN),^ HSPD-5,*’' and the Federal Response Plan,*^ the following command and 
control functions — relevant to data coordination and plume modeling — were followed for 
Federal agencies during the FSE: 

• DHS was designated the LFA, and coordinated the response from all Federal agencies; 
and 

• DOE and EPA were technical support agencies to the LFA for the radiological aspect of 
the response; DOE was further responsible for coordinating the activities of the FRMAC. 

d. Coordinating the data 

There are many responders that can collect on-site and off-site radiological data following an 
explosion containing radioactive materials. To develop reliable (i.e., consistent) and valid 
information for decision-makers, it is impt^rtant that the data collection effort be coordinated 
both on the ground and in terms of how the data flows and is turned into useful information for 
decision-makers. Coordinating the data flow can ensure that SMEs have all of the available data 
to use for analysis. This is one step to ensuring that the output — the information provided to 
policy makers and top officials — is consistent and valid in terms of the empirical data. 
Coordination on the ground also helps to minimize the likelihood that multiple agencies will 
perform redundant tasks or repeat tasks because of conflicting data reports. This is vitally 
important in an incident where responders face a high-risk environment. 

The Washington State DOH Division of Radiation Protection Plan and Procedures for 
Responding to a Radiological Attack describes how the DOH should coordinate their 
radiological response on-site and with the FRMAC. Prior to the arrival of the FRMAC, the State 
Health Liaison (SHL) facilitates communication between the DOH staff at the Washington State 
Emergency Operations Center (EOC) and incident command regarding appropriate protective 
measures and decisions. The SHL provides the WA State EOC with radioactive release data, 
weather data, radiological data collected by field teams, predictive plume maps, and dose 
projections. Once the FRMAC is established, the SHL or Deputy State Health Liaison (DSHL) 
relocates to the FRMAC and assumes the role of FRMAC liaison. The WA State DOH response 
plan leaves the details of the coordination effort up to the SHL (or DSHL) and the FRMAC, 
which provides for the flexibility needed for each individual response. The FRMAC liaison is 
responsible for coordinating the State’s response with the Federal response and for maintaining 
communication with the RMAC, the WA State EOC. and the Joint Information Center (JIC). 
Furthermore, the FRMAC liaison is responsible for determining when and how Washington 
State’s response will be integrated with the Federal response.^'’ 

Typically, upon arrival at a crisis, the FRMAC Director works to coordinate with State and local 
agencies through an advance party meeting. The goals of the advance party meeting are to 
ensure that Federal representatives in the FRMAC are up-to-date on the crisis, identify points of 


The Federal Radiological Emergency Resptmse Plan (FRERP) (50 FR 46542), of 1 1-8-85. revised 1996. 

United States Government Interagency Domestic Terrorism Concept of Operations Plan. 

Homeland Security Presidential Directive/HSPD-5, February 28, 2003. 

Federal Emergency Management Agency, Interim Federal Response Plan, January 2003 (9230. 1 -PL). 

Washington State Department of Health, Division of Radiation Protection Plan and Procedures for Responding to 
a Radiological Attack, DOH/DRP, March 2003. 


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contact for state representatives, and develop protocols for providing data products to top 
officials and SMEs at state and local EOCs and relevant agencies. The advance party meeting is 
a critical step providing unique information during each emergency — different states have 
different relationships with county and local governments; the FRMAC representatives need to 
understand these relationships to provide effective support. The Federal response effort relies on 
state representatives to help facilitate these relationships. State and local radiation experts are 
also invited into the FRMAC to provide a liaison between the Federal response assets and the 
state and local governments. By having state, and potentially local, representation at the 
FRMAC, local decision-makers are still relying on their own people for recommendations. These 
SMEs, however, have additional support from the Federal Govemment.^’*'^ 

e. Plume Modeling and Deposition Maps 

In an RDD explosion, the bomb throws radioactive material into the air; the resulting radioactive 
debris cloud is called a plume. In the early hours following die explosion, the National 
Atmospheric Release Advisory Center (NARAC), the National Oceanic and Atmospheric 
Administration (NOAA), and the Defense Threat Reduction Agency (DTRA) can generate a 
prediction of the plume boundaries using sophisticated models. There are also several less 
sophisticated models available to develop a plume projection. To generate predictions, agencies 
need some basic information about the explosion and the radiological material involved (defined 
as the source term), the weather, and the topography surrounding the incident site. As more 
information about the explosion becomes available, the source term and the initial prediction are 
refined. Top officials can use these predictions to make preliminary decisions involving first 
responder safety, safe transit routes, and protective action guidelines for the public. The first 
plume prediction generated for SFD on May 12, 2003 by the Lawrence Livermore Atmospheric 
Release Advisory Capability (ARAC) model overlaid on the map of the Seattle region affected 
by the RDD explosion is shown in Figure IQ.^ 



^ The Federal Radiological Emergency Respon.se Plan (FRERP) (50 FR 46542), of 11-8-85, revised 1996. 
“ Information obtained from personal communication with FRMAC personnel. 

^ For a detailed discussion of plume dispersion models, see the Stanford Report, an appendix to Annex B. 


71 



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Figure 10. NARAC-Predicted Contamkfated Areas 

1 

The plume predictions, alone, decrease in value after the first few hours following an RDD 
explosion. Knowledge about the type and amount of radionuclide released (as well as the 
physical form and chemical composition of the substance used) limit the modeler’s ability to 
generate a plume prediction map that accurately reflects the release. The radioactive particulate 
matter that deposits on the surface during the passage of the plume can be measured by 
collectkig empirical data with field-team and aircraft-based sensors. As more data are collected, 
a more accurate picture of the amount of radiological material deposited is developed. Initial 
measurement data can be used to update model predictions and produce a better prediction for 
areas &at have not yet been surveyed. (For example, this was done during the FSE in the 
FRMAC using NARAC models to project areas that may have had low levels of food crop 
contamination in western Washington State.) Predictions updated with measurement data can 
also be used to make estimates of areas that have contamination below the measurement 
threshold of available instruments. When detailed measurement surveys are completed and the 
data analyzed, they can be used to determine the most accurate picture of the amount of 
radioactive material deposited. With these data, accurate assessments of protective actions can 
be made and used by top officials to confidently make informed decisions. 


Ii»n 

MVatn, 


TOPOFF 2 Exerclit 

1 Hour Integrated Air Concentration *** *■ Esplostan of Unknown Material 


ttAMC.ewp C9r. X* I 


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U3 

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i 


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^ o w.-u Progx06Mw2DD3a0130DUTC 
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Sotn* bc«l«d tJ 133 325378 W 

O«o««t*d 06 M«7 2QD3 3030 03 UTC 
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f av or phdnt<^25) 43* 6465 


To be useful in managing the safety of victims or responders, the numbers characterizing the 
deposition of radioactive material on the ground must be turned into numbers chaiacterizing the 


72 


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dosage that a human would receive, and of more importance to top officials, into 
characterizations of the health impact of such a dosage. Figure 1 1 is a FRMAC data product that 
shows the radiological deposition on May 14, 2003 in terms of ERA PAGs. This product was 
generated based on a FRMAC assessment of measurements of the deposited radioactivity, and 
used the NARAC model to determined ERA PAG levels in between measurement points. 



EXERCISE 


TOP OFF 2 


EXERCISE 


N.4RAC S«l II Esr]> Phuv 
and Rdocadnn PAC* 

May 14. 2003 0830 PDT 


Otnnii 




Showing the Deposition of Radioactive Material in Terms 
Agency’s Protective Action Guidelines 

;esses involved in developing plume predictions and deposition data 
the differences between plume predictions and deposition, footprint 
each can provide the decision-maker. 


73 



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Reports Other 



Figure 12. Processes for the Development^fi^^me Prediction and Deposition Maps 


3. Reconstruction 
The following teams all c 
• City assets 


^[fet acLrad iok 


Y 


adiolo^al data during the T2 FSE; 


67 


o ^Seattle Fire Department HAZMAT 



State assets 

1 \ 

o National Guard 1 0"* WMD CST 
o W^Ungton State DOH RMAC and Field Teams 
Washington State Department of Ecology Field Team 


The evaluation team learned that the ATF Bomb Squad carried radiation detectors that they used to collect data 
for their personal use. It is possible that there were other agencies whose personnel were also wearing radiation 
detectors. US Navy personnel from the Fhiget Sound Naval Shipyard were also tasked during the FSE to collect 
radiological data for the FRMAC. It is possible that the evaluation team is unaware of other agencies that collected 
radiological data during the FSE. 


74 






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• Federal assets 

o DOE RAP Region 8 Team 
o DOE Aerial Monitoring System (AMS) 
o EPA Field Team 
o FRMAC Field Teams 



WA Siaie DOH 
Public Heullh Lab' 


As shown in Figure 13, no single agreed upon agency served as a central clearinghouse for all of 
the radiological data collected by the different teams. Data were collected and sent to multiple 
agencies for analysis, but no one agency received all of the data. 


RMAC 


Incident Command: 
Opcralions 


WA Suite Dept, of 
Health Field Team 


Dtih KAP learn 


DOF Acnal 
Monitoring System 


l-RMAC Field 
t'eaiiis 


SFD HazMal 



HazMal Lead 





EPA Field 
Team' 


FRMAC 


*DOH Lab also sent results to the WA State EOC 




figure Pata Coordination during T2 FSE 


DatatransferonMay 12-14 
— — — — ► Data transfer on May 13-14 


75 










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The following agencies/organizations generated and distributed plume predictions and/or 
deposition maps during the FSE: 

• State and local 


o SFD/Seattle EOC 

o Seattle/King County Public Health EOC 
o King County EOC 
o Washington State DOH RMAC 
• Federal 

o FRMAC 
o HHS Headquarters 
o NOAA 

o DOE Headquarters 

Figure 14 indicates that many data products were produced by many'^ferenForganizations. The 
distribution of these products also proved to be a challenge durin^^dfe ESE.* 






“ According to a Washington DOH controller after the FSE, data was sent from the RMAC to the Seattle EOC, but 
the evaluation team could not confirm that information. 


76 



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•RMACsentrawdaUtothe EOCsand«otheFRMAC ^ D«tfibudon on May 12 -14 

— “ — — ► Disiribudon on May 1 3 -14 


Figure 14. Data Interpretation and Distribution during T2 FSE 
a. Seattle 

Soon after the explosion, SFD generated a prediction of the plume using the ARAC model.^ It 
is not clear, however, if the initial plume prediction generated by SFD ever left the incident site. 
All other plume predictions were generated by NARAC upon request and made available to 
agencies via the NARAC secure Internet site. Distribution of NARAC predictions to other 
agencie.s (beyond Seattle) required approval by the DOE Senior Energy Official, who was 
responsible for coordinating the use of DOE assets (such as NARAC) with other agencies. 
Agencies tiuit (lad access to the NARAC secure Internet site included SFD, Seattle Police 
/ 

Seattle is the first city to pilot the Local Integration of NARAC with Cities (LINO program. TTie program was a 
pilot project of the NNSA, and is now in DHS. It enables local responders to access NARAC's plume modeling 
capabilities. Using the sy.stem, the Seattle Fire Department (SFD) can receive NAIUAC plume model predictions 
using previously installed computer systems. The NARAC predictions can ea.sily be distributed to multiple 
recipients. For more information, refer to NNSA 's Livermore Lab Partners With Cities anti Counties to Track 
Biological, Chemical Releases. Lawrence Livermore National Laboratory News Release, NR 02-05-08, May 22. 
2002 . 


77 










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Department (SPD), Seattle EOC, Public Health Seattle/King County (PHSKC) EOC, King 
County EOC, WA State EOC, WA DOH, DHS, Federal Emergency Management Agency 
(FEMA), DOE, DOD, Department of Transportation (DOT), HHS, (NRC, and EPA. 

b. Washington State 

The Seattle EOC notified the WA State EOC that SFD responders detected radiation at the 
incident site at 1225 Pacific Daylight Time (PDT). The WA State EOC deployed the following 
assets: 

RMAC 

The WA State DOH deployed their mobile RMAC to the incident site shortly after the WA State 
EOC received notification that radiation was detected. By mid-afternoon on May 12, 2003, the 
RMAC gleaned enough information off the radio to develop a source term and generate its own 
plume projection using a modeling program called HotSpot. The RMAC also deployed field 
teams that were collecting data by 1530, and obtained off-site readings by 1900.’'’ 

The RMAC had considerable communications problems throughout Oie exercise — that could 
have Just as easily occurred in a real incident. During the aflemoon and evening of May 12, 
2003 and the morning on May 13, 2003, the RMAC was only able to transmit data points to the 
WA State DOH staff at the WA State EOC via telephone. Those data points were plotted on a 
map at the WA State EOC. The RMAC also used the EPA’s wireless Internet capability to send 
graphics to the DOH staff. However, the file was not recognized as containing graphics and was 
not opened immediately. At 1455 on May 13, the RMAC used the DOE Region 8 RAP Team’s 
fax machine to transmit three pages of field team data. Because of the lack of resources at the 
WA State EOC to plot data and the considerable lag time to receive data, the Division of 
Radiation Protection Director began identifying significant data points and briefing them directly 
to decision-makers during conference calls.”’ 

The RMAC also sent data to the King County and PHSKC EOCs and to the FRMAC during the 
exercise. The DOH liaison at the King County EOC began sending a courier to the RMAC to 
pick up their radiation data on the morning of May 13. 2003. Plotters in the King County 
Geographic Information System (CIS) section then plotted the data points on a map and 
forwarded it to the WA DOH staff at the WA State EOC. The DOH liaison at the PHSKC EOC 
received data over the telephone and plotted it on a map. By late afternoon on May 13, a DOH 
liaison went to the FRMAC to initiate a protocol for transmission of data. Because of 
communications problems, the FRMAC did not begin to receive DOH RMAC data until May 
14.’^ The Seattle EOC does not recall ever receiving data or products from the RMAC or the 
WA State DOH. 

DOH Public Health Laboratory 

The DOH Public Health Laboratory was activated to analyze soil samples. They received soil 
samples from the DOH field teams, EPA field teams, and FRMAC field teams. To test their 


RMAC teams were likely on site earlier but there are no data to confirm this a.ssertion. 

The recon.stniciion of events at the DOH RMAC was obtained through conversations with Washington DOH staff 
who participated in the exercise. 

Information regarding data transmission from the RMAC was reconstructed from conversations with Washington 
DOH and FRMAC staff who participated in the exercise. 


78 



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internal policies and radiation analysis capabilities, the lab arranged to receive radioactive soil 
samples prepared prior to the FSE. For purposes of the exercise, these samples were tagged as 
though they came from SFD HAZMAT, EPA, and Harborview Hospital. The results were sent 
to the RMAC and to the WA State EOC. 


Department of Ecology 

At 2000 on May 12, the WA State EOC was prompted by exercise control to contact the 
Department of Ecology and have them deploy their HAZMAT team resources to survey the 
surrounding area. At 2312 a data collector observing incident command recorded the Operations 
Chief instructing the Ecology Field team to do off-site monitoring. The Ecglogy Field Team 
data were sent to the RMAC. 


t 


National Guard l(f'' WMD CST 

The WA State EOC notified the National Guard lO'*’ WMD CST ^ go oiiTstanSby at 1230 on 
May 12, 2003. They were instructed to deploy to the City of3|^atac^d await further 
instructions. At 1345, the CST received notification from the W;^' State-EOClto deploy to the 
incident site.’^ The CST advance team arrived at the incident site af approximately 1415, and the 
CST commanding officer met with the Incident Commander at 1420. The CST commanding 
officer was instructed to check in with the SFD Operations Chief and report directly to the 
HAZMAT Chief. After an initial assessment, the CST commanding officer brought in the rest of 
his team at 1445. The CST sent their data to the SFD HAZMAT Chief and to their MATS. 
They also collected ground samples that the EPA sent to the WA State DOH Public Health 
Laboratory for analysis. The CST was redeployed at approximately 1230 on May 13, 2003 and 
told to remain on stand-by in case there were follow-on attacks. 

c. Federal data collection and modeling 

The following Federal assets were deployed to Seattle and the .surrounding areas; 

EPA 

At 1318 on May 12, 2003, EPA regional field personnel were dispatched to the incident site. 
When they arrived on scene, EPA personnel communicated with incident command and were 
tasked with monitoring the perimeter and taking air samples. EPA personnel began monitoring 
and sampling at approximately 1430; they continued to take air and soil samples throughout the 
exercise. EPA responders provided their data to incident command through the Incident 
Command System (ICS) reporting chain. EPA responders also provided data back to EPA 
Region 1 0 Regional Response Center (RRC). While EPA has procedures to provide off-site data 
to the FRMAC during a fixed-facility incident, procedures for integrating on-site data into the 
FRMAC were not been provided to the EPA field teams during the FSE.'"* As a result, while 
EPA personnel knew to send their data to the FRMAC. no data were sent to the FRMAC until 
May 14. 


The CST deployed to the exercise staging area prior to the start of the exercise. They waited there for the 
appropriate amount of time as if they were following the deployment orders described above. 

As will be discussed later in the section, EPA data was not provided to the FRMAC until May 14 because no 
advance party meeting was held during the FSE. 


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DOE Region 8 RAP Team 

At 1335 and 1336 respectively on May 12, 2003, the Region 8 RAP received calls requesting 
assistance from the WA DOH and the Federal Bureau of Investigation (FBI). Within two hours, 
the team completed their pre-deployment activities and was en route to the Seattle area by 1458. 
Through discussions with both the FBI and WA DOH, it was agreed that RAP would initially put 
all their resources and effort to support the FBI. Upon arrival at the scene, RAP teamed up with 
the FBI Hazardous Material Response Unit (HMRU) Commander, informed him of team 
capabilities, and received a safety brief prior to commencing survey onsite. RAP supported the 
FBI until 2400 on May 12 and continued to support the FBI on May 13 until 1100. RAP 
received numerous requests for assistance from the Environmental Protection Agency (EPA), 
who were conducting on-site surveys, and the Disaster Mortuary Operational Response Team 
(DMORT). RAP fulfilled these requests and supported WA DOH with their requested priorities 
into the evening of May 13. On May 14, RAP was able to fulfill a request to join the FRMAC. 

DOE AMS 

A data collector at the WA State EOC recorded that the deployment order for the AMS was 
received at 1425 on May 12. 2003. The DOE AMS arrived over Seattle at approximately 1900 
and flew a serpentine pattern to collect notional radiological data. The data were transmitted to 
the FRMAC at 2056. The AMS flew several more times over targeted locations during the FSE. 

FRMAC 

After some discussion among Washington St^ top officials concerning the need for the 
FRMAC. the DOH made a request to FEMA to deploy the FRMAC at 1434 on May 12, 2003. 
DOE Headquarters in Washington, D.C., approved the FRMAC deployment at 1549 that same 
day, and they departed from Nevada at 1600. At 2(X)0 the WA Slate EOC received confirmation 
that the FRMAC was in place at Fort Lawton. 

Upon establishment of the FRMAC, Field Monitoring Teams were deployed. At 2056 on May 
12. 2003, the FRMAC began to receive simulated empirical aerial sampling data from the DOE 
AMS. The ground monitoring data obtained indicated the presence of an alpha emitter in 
addition to the gamma emitter identified earlier in the day.’^ With data still limited, the FRMAC 
Director briefed the initial results to the PFO at around 2300 on May 12 and recommended to the 
PFO that the affected people be evacuated. However, EPA advised the PFO that the Seattle 
Mayor's shelter-in-place order should not be revised, and that the decision could be re-examined 
in the morning based upon additional monitoring data. The PFO’s final decision was to 
recommend to the Seattle EOC that they maintain the sheller-in-place until morning when a more 
thorough analysis would be completed. Before the PFO could pass his recommendation to the 
Seattle EOC, however, he learned that a decision had already been made by the Seattle Mayor to 
release those workers who had been sheltered within their businesses, and for residential citizens 
already sheltering-in-place to remain doing so. 

The FRMAC did not have the time to complete a radiological deposition map that showed the 
health impact of the radiation dose on the public in terms of EPA PAGs before the Joint 
Operations Center (JOC) closed at 2300. FRMAC protocol required approval from the FRMAC 


Data collector logs show that the DOH Public Health Lab also identified the presence of an alpha emitter at 
around the same time. 


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Director, the Senior Energy Official (SEO), and the PFO — all of who were stationed in the 
JOC — before all analysis products could be distributed. Because the JOC was closed, the 
FRMAC could not obtain necessary approval to distribute the maps showing the radiological 
deposition to the other FSL operations centers until the following day. 

At 0800 on May 13, 2003, FRMAC briefed the most up-to-date deposition map to the PFO. A 
more rigorous analysis revealed that an evacuation was not necessary, but a targeted relocation 
would be required. The PFO approved the release of the deposition map to the DHS Crisis 
Action Team (CAT). At 1000, FRMAC participated in a conference call with the PFO; the 
Seattle, King County, and WA State EOCs; and the FEMA Regional Operations Center (ROC). 
During that call, the FRMAC Director provided the EOC representatives with a summary of the 
data collected thus far. With this knowledge, in addition to the determination by WA DOH that 
the areas east of Interstate-5 (1-5) were contaminant-free, the Seattle Mayor was comfortable 
moving forward with his decision to release those residents sheltering-in-place east of 1-5 and 
relocate affected residents west of 1-5 for three days. Later that day, at 1220, the Seattle Mayor 
and the Public Health Seaftle/King County Director met with the FRMAC Director and the PFO 
at the JOC to review the FRMAC deposition map. 

After that meeting, the distribution of a consistent data product appeared to improve. Requests 
started to appear in the FRMAC activity log from the Seattle EOC and the WA State EOC for the 
most recent maps. The FRMAC responded to these requests anywhere from immediately (to 
DHS) to five hours, 38 minutes later (see Table 5). This timeframe provides a realistic sense of 
how long it takes for information to get out of the FRMAC once the contacts are established. 
Top officials and SMEs need to remember that the FRMAC is inputting data collected from 
many sources, and that before they distribute updated information, they need to input the data 
into their system, conduct an analysis of the data, and get approval from the appropriate 
authorities. This process takes time and is often shortened during training exercises. 



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Table 5. Request and Delivery of F RMAC Data Products 


Requesting agency 

FRMAC PRODUCT ! 

REQUESTED 

FRMAC PRODl^CT 

DELIVERED 

Time difference 

DHS 

May 13 0851 

May 13 0851 

0:00 

DOE Headquarters 

May 13 0911 

May 13 0920 

0:09 

FEMA ROC 

May 13 0919 

May 13 1239 

3:20 

DHS 

May 13 0954 

May 13 1359 

4:05 

Washington DOH 

May 13 1137 

May 13 1715 

5:38 

SFD 

May 13 1143 

May 13 1607 

4:24 

Seattle Mayor 

May 13 1147 

May 13 1402 

2:15 

Washington 

Department of 
Agriculture 

May 13 1222 

May 13 1735 

5:12 

WA State EOC 

May 13 1318 

May 13 1723 

4:05 

Food and Drug 
Administration 

May 13 1901 

May 13 2206 

,3:05 

EPA 

May 13 1909 

May 13 2026 

1:17 

King County EOC 

May 14 1055 

May i71247 

1:52 


Many agencies and departments outside of Washington State contacted the FRMAC directly for 
maps and other data products on May 13 and 14, 2003. The FRMAC Event Log shows requests 
for deposition maps from DHS, Food and Drug Administration, ERA. and DOE Headquarters. 
These examples suggest that the Federal agencies participating in Washington, D.C., understood 
that the FRMAC would coordinate the radiation data and distribute the updated deposition maps. 
However, even though they had representarives in the A-Team — which was co-located with the 
FRMAC — deposition maps could not be sent to the Centers for Disease Control and Prevention 
(CDC) and the HHS operations centers.’^ 

d. Federal agencies and department headquarters 

The following Federal agencies used their own internal models to develop maps at their 
headquarters: 

DOE 

DOE Headquarters in Washington. D.C., accessed the same NARAC plume predictions as those 
used by agencies working in the Seattle area (such as in the Seattle EOC and the FRMAC), using 
the same secure Internet site as used by other agencies. As DOE was assigned initial 
management of FRMAC for radiological response, it is likely that their plume map was used to 
brief top officials. 


The evaluation team does not know if this wa.s because of technical problems or if the Advisory Team did not 
have the permission to distribute the FRMAC products. 


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HHS 

On May 12, 2003, HHS Headquarters in Washington, D.C., developed a plume prediction using 
DTRA’s Hazardous Predicting Assessment Capabilities model. They used an unknown scenario 
to generate their inputs for the model. Observations by data collectors suggest that they 
developed the plume projections to identify HHS assets that might be required and eventually 
deployed. These maps were used to brief the HHS Secretary and DHS Secretary during the FSE. 
Since the model used to generate the HHS plume prediction differed from the one used to 
generate the DOE plume prediction, it is likely that the outputs differed as well.’’ 

NOAA 

NOAA also generated plume predictions during the exercise. They too used unknown scenario 
estimates to input into their model. In addition, NOAA used real weather patterns for their 
model rather than the canned weather planned and used during the T2 FSE. NOAA intended to 
run their model for training purposes only, and the resulting plume prediction was to be walled 
off from inter-agency play. Nonetheless, copies of the maps were faxed to the DOE 
Headquarters during the exercise. The addition of another plume prediction generated with yet 
another model and resulting in a different output from the two others may have added to Federal 
top officials’ frustrations.’** 

EPA 

The evaluation team does not have any data to indicate that the EPA Headquarters generated a 
plume prediction during the exercise. However, diere are data that indicate that the White House 
contacted EPA Headquarters for a plume map. 

4. Artificialities 

A number of exercise artificialities contributed to the data coordination and analysis product 
distribution challenges were observed during T2. These included: 

• The JOC was closed from 2300 on May 12, 2003, until 0700 on May 13,2003; 

• There was an insufficient number of controllers to provide injects to agency personnel 
collecting radiological data at the RDD incident site. This was especially problematic 
during the overnight hours of May 12 to May 13, 2003. In addition, the WA DOH 
RMAC did not have an exercise controller located in their facility; 

• The FRMAC expected the affected area to become smaller over time due to the re- 
wetting of contaminated material. However, exercise controllers did not have the pre- 
scripted data to support the re-wetting process; 

• The location of the FRMAC was unrealistic, as it was located in a contaminated area; 

• While there will always be security at an incident site, particularly if WMD are 
suspected, security during the FSE was slow and cumbersome; and 


’’ The evaluation team does not have sufficient data or plume prediction maps to compare the results from the 
different models 

Again, the evaluation team does not have sufficient data to compare the results from the different models. 


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• The events leading up to the RDD at the Columbia Generating Station would have caused 
most State assets to be deployed to Richland. This would have delayed their response to 
the RDD incident in Seattle by hours. 

5. Analysis 
a. Plume modeling 

As described in the reconstruction, the Seattle HOC contacted NARAC soon after the explosion 
to have them generate a prediction for where the plume would travel. The resulting product was 
made available to the King County and WA State EOCs as well as the FEMA ROC and other 
Federal and State agencies. To add to the confusion, the State DOH RMAC generated another 
plume prediction using the HotSpot modeling program, once they obtained enough data to input 
a reliable source term.’^ As de.scribed in the reconstruction, the RMAC used EPA’s wireless 
Internet capability to send their plume prediction to the WA State EOC. As a result, Seattle, 
King County, and Washington Slate top officials all had different information from which they 
could make their preliminary decisions. The evaluation team does not have sufficient data to 
determine whether each jurisdiction had multiple plume prediction maps or whether they simply 
had different plume prediction maps. In recognition of the fact that data availability is likely to 
be very limited early in an RDD response, WA State DOH, PHSKC, and EPA developed default 
PAGs, based on the existing PAGs, to use during an RDD event. The Seattle Mayor applied 
these “default" PAGs during the early hours of the incident, as decision-makers awaited the 
collection of the data required to effectively model the release. Therefore, it is not clear if the 
presence of different plume predictions affected local and State top official decisions in the early 
hours of the exercise. 

In addition to the confusion in Seattle, several Federal agency and department headquarters 
developed their own plume predictions to make internal assessments concerning assets that 
might be required. These Federal agencies and departments all used an unknown scenario to 
generate input data and used different models to generate plume predictions. So even if the input 
data were the same, the output may well have differed. As noted earlier, the evaluation team was 
told that many of these agencies generated the predictive maps for internal purposes — either for 
training purposes or to provide them with some insight into what Federal assets might be needed 
for the response. Nonetheless, during the T2 FSE, multiple maps from the predictive models 
were presented to department and agency top officials in Cabinet-level meetings. This led to 
some confusion and frustration by top officials in Wa.shington, D.C., as to which output was the 
correct one to use. Although the evaluation team did not identify that the existence of multiple 
maps produced any direct consequences upjon decisions made during the FSE at the Federal 
interagency level or in Washington State, the issue may have contributed to delays in decision- 
making. This underscores the role of the FRMAC as the single place to coordinate and analyze 
data, and to provide authoritative data products to support decision-makers, in accordance with 
the FRERP. Decision-makers need to understand that this process takes time, and that the 
empirically-based data products provide more accurate information than initial plume predictions 

Furthermore, it is easy to imagine the possible consequences of FSL governments producing 
many different maps, particularly if they have used different measurements and standards. 


79 


The evaluation team does not have sufficient data or plume maps to compare the results from the different models. 


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While it didn’t happen during the FSE, the media could have questioned the FSL governments’ 
expertise and ability to make decisions. 

In the region close to the incident site where protective action decisions are most important, 
estimates based on atmospheric models are very uncertain. For very large-scale decision-making 
(e.g., identifying the ingestion pathway), models may be more useful but are generally applied 
with conservative assumptions that reduce their usefulness. In the case of TOPOFF 2. projections 
exceeding FDA criteria out to 150 miles from an RDD in downtown Seattle were not credible 
and potentially could have resulted in unnecessary food protection actions. 

Finally, and possibly most importantly, it appears that few decision-makers were informed of the 
fact that a plume prediction has a limited useful lifetime. As discussed in the introduction to this 
section, model predictions need to be continuously updated using real measurement data, and 
will be replaced by products generated primarily from measured data, once enough data are 
collected, interpreted in a manner understandable to top officials, and the resulting products 
distributed. During the FSE, top officials emphasized their frustration regarding the different 
plume maps. However, they did not ask for (or in some cases receive) updated information that 
relied on empirical data. This suggests there is a need for additional education among both 
responders and decision-makers regarding the timing and value of the different types of 
information following an RDD explosion. ^ 

b. Data collection and coordination 

As described in the reconstruction, there was minimal coordination of radiological data 
collection between FSL agencies at the incident site or at off-site locations until the third day of 
the exercise. Many FSL agencies with various data collection capabilities arrived to the incident 
site at different times. A.s in any mass casualty incident. Incident Command has many 
responsibilities, including the primary mission of rescuing victims, all of which require the 
Incident Commander’s attention. This can easily stress incident command capabilities, and limit 
attention to many tasks — particularly relatively specialized or complicated tasks. 

During the FSE, there is evidence to support the fact that the Incident Commander tasked the 
EPA field team and the CST to work together to coordinate monitoring and sampling at the site, 
and report their data to the HAZMAT Chief. While there is evidence that WA DOH RMAC was 
in contact with Incident Command, it is unclear what information was shared. However, there is 
no evidence to indicate that WA State DOH RMAC coordinated their collection efforts with the 
Incident Commander or with the HAZMAT Chief. Rather, the data indicate that the Washington 
DOH RMAC. DOH field teams, and the Washington State Department of Ecology field team 
coordinated with each other on May 12, 2003. but not with the other local or Federal data 
collection agencies at the incident site. By May 13, 2003, the EPA and DOE RAP teams were 
also coordinating with the DOH RMAC. 

The result of the on-site coordination failure is that no one agency at the incident site had all of 
the data. In addition, some responders entered contaminated areas to collect data that another 
agency had already collected, which meant they were exposed to more radiation than necessary. 
As a consequence, FSL responders, collecting data for different purposes, duplicated on-scene 
efforts. As an example, during the on-scene Hotwash, EPA learned that a bomb squad had sent 
robots into the most contaminated areas armed with radiation meters, which were then read from 
a distance using cameras. Because this data was not integrated in the incident command system 


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and shared with all responders, EPA field teams later collected these same data points again, 
resulting in perhaps unnecessary exposure of pjersonnel to radiation. In addition, as the 
uncoordinated data left the incident site, different jurisdictions (i.e., Seattle, King County, and 
Washington State) had different data from which they developed information to make 
recommendations and decisions. 

While coordination challenges on the ground and among agencies are to some extent expected 
early during the incident response, the arrival of the FRMAC (2000 on May 12, 2003) is 
designed to facilitate at least more organized off-site data coordination. As discussed in the 
Background of this section, one of the first steps the FRMAC typically takes upon arrival at a 
radiological incident is to hold an advance party meeting with representatives from the State and 
other Federal agencies. The advance party meeting is designed to facilitate relationships with 
relevant Federal, State, and local officials, and to put processes in place to facilitate the 
coordination of data and the distribution of information to all relevant agencies. 

During the FSE, the advance party meeting did not occur. DOH staff at the WA State EOC 
made the decision to not send a liaison to the FRMAC based on how busy DOH personnel were 
in the opening hours of the FSE and a lack of understanding of the importance of the advance 
party meeting and co-location with the FRMAC. To further complicate issues, that decision was 
not communicated to the RMAC; so they were unaware that the FRMAC had even arrived. The 
lack of an advance party meeting meant that neither State nor Federal agencies had the 
opportunity to develop and agree on procedures to send data to a single analysis location — which 
presumably would be the FRMAC. As a result, the only data the FRMAC had on May 12, 2003 
was from the AMS and from their field monitoring teams. As described in the reconstruction, 
the FRMAC did not receive data from the RMAC, EPA, or the DOE RAP Teams until May 14, 
2003. The lack of on-site coordination also makes it unclear if the FRMAC ever received data 
collected by the SFD HAZMATTeam. 

EPA participants suggested a possible means of supporting coordinated data collection efforts. 
They suggested that it would have been beneficial if all of the technical agencies collecting data 
at the incident site had come together to present unified recommendations on roles and 
responsibilities to the Incident Commander. They also suggested that it would have been 
beneficial for one of the technical agencies to volunteer to coordinate all of the data being 
collected on the site. Although this might have helped coordinate the data, it would require one 
of these support agencies to take the lead in coordinating the effort. A potential middle ground 
would be for Incident Command to track which teams are on-site collecting data, and task one of 
the support agencies to coordinate the effort. This would provide Incident Command with both 
the unified front they lacked during the T2 FSE, and an SME to coordinate and possibly provide 
expert advice. Further, this would give these critical SMEs greater visibility with Incident 
Command than they had during the T2 FSE, where they were working for the HAZMAT 
Chief — two levels below the Incident Commander. 

Data collection, management, and distribution continue to be a challenge at nationally significant 
incidents. FRMAC procedures, which were developed primarily for radiological releases from a 
fixed nuclear facility, should be re-examined to ensure that they are effective in handling non- 
fiixed facility incidents involving on-scene response by FSL responders. Although the plan was 
modified since its original inception, the procedures remain modeled on response methods 
appropriate for nuclear reactor disasters. Further, the Washington State DOH Procedures for 
Responding to a Radiological Attack is written to integrate into existing FRMAC and other DOE 


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plans. When applied to terrorist events, like that simulated during T2, there are differences that 
may impact the effectiveness of these procedures. These include: 

• Disasters at nuclear facilities are likely to involve known radiological materials and 
estimates of quantities involved, whereas the materials and quantities used in terrorist- 
sponsored RDD explosions are not known until analyses can be completed, as was the 
case in the T2 FSE; and 

• Terrorist activities are more likely to occur in major metropolitan areas with high profile, 
politically powerful, and well-equipped local governments; whereas nuclear facilities 
tend to be in rural communities with fewer response assets. In Washington, the DOH 
Procedures for Responding to a Radiological Attack only acknowledges a local 
jurisdiction's leadership role at an incident when “command shifts or transitions to local 
jurisdiction,” rather than assuming that the local jurisdiction is in charge and that the 
State is a support agency***’. This may stem from their experience or responsibilities for 
nuclear power facilities, or their internal expectations. 

As DHS develops its plans for responding to radiological (and other) emergencies, it is 
imperative that they build in processes that allow State and local government capabilities to be 
coordinated with the federal capabilities. This is particularly important because state and local 
resources are likely to arrive on the scene and begin u,sing their assets before the federal support 
arrives. 

Another issue that deserves further attention is whether the FRMAC should release raw data sets 
to different agencies, or to continue to send out only data products. In T2, the FRMAC policy 
was to collect and analyze data locally, and only send out data products. A number of Federal 
and State agencies suggested that they need the raw data to conduct their own analyses, and that 
the FRMAC policies do not allow them to meet their missions. However, were data to leave the 
FRMAC. there is greater potential for many agencies to have incomplete or out of date data. This 
could further complicate the coordination challenge and increase the likelihood of inconsistent 
decisions and public information. 

c. Data analysis, distribution, and impact on decision-making 

Developing the most valid deposition maps possible requires that all data be sent to the SMEs 
who are interpreting the data. As far as the evaluation team has discerned, the radiological data 
collected by the SFD HAZMAT never left the incident site, and might not have been used to 
develop deposition maps. In addition, there is no evidence that any of HAZMAT data were sent 
to the RMAC or the FRMAC to support their analyses. Therefore, it is quite likely that none of 
the agencies analyzing radiation data were using all available data. This is one reason that 
different analyses could result in different information being sent to top officials. As described 
earlier, the WA DOH, IHiblic Health Seattle/King County, and EPA recognized the likelihood of 
limited data reaching decision-makers early in an RDD response and developed default PAGs 
prior to the FSE. The Seattle Mayor used these default PAGs during the early hours of the 
incident. 


Wa.shington Stale Department of Health, Division of Radiation Protection Plan and Procedures for Responding to 
a Radiological Attack, DOH/DRP, March 2003. 


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However, even if the data coordination challenges did not exist, analysis product distribution was 
another challenge for responders during the FSE. Prior to the arrival of the FRMAC, the WA 
State DOH. King County EOC, and PHSKC plotted rough deposition maps using data collected 
by the WA DOH field teams. As noted in the Reconstruction section of the AAR, lack of 
resources made it difficult, if not impossible, for these maps to be interpreted and reach decision- 
makers in a timely fashion. Therefore, significant data points served as key discussion points 
during conference calls to help top officials make decisions. 

The impact of the lack of clear information led to significant frustration among top officials. A 
number of T2 data collectors observed the frustration and noted players' attempts to resolve the 
frustrations on their own. For example, at 2100 on May 12, 2003 a data collector at the Seattle 
EOC recorded that the Mayor’s representative told the WA DOH that they wanted to make-up 
their own data to develop the information they needed to define an evacuation route. A data 
collector recorded similar statements at the WA State EOC. Although the evaluation team does 
not know whether Seattle or Washington State followed up on its quest to make up radiological 
data, these observations do illustrate the problem. 

The evaluation team identified four potential contributing factors that may have led to the 
frustration experienced by the State and local top officials during the overnight hours of the 
exercise: 

• It is likely that there was insufficient scenario data during the overnight hours (see 
artificialities)', 

• Controllers in the WA State EOC gave conflicting information to DOH personnel and 
also withdrew information that had been provided earlier in the exercise; 

• As described in the reconstruction and in the previous section, there was also a lack of 
effective coordination, until the third day of the exercise; and 

• It is possible that top officials did not recognize the real amount of time that it takes to 
collect, coordinate, and analyze data and present it in a meaningful fashion. Many top 
officials are used to participating in tabletop exercises where the data and information 
they request are made available much more quickly than would happen in real 
emergency — in tabletops, data and information are often available instantly. 

The timing of the statements .showing top official concerns on May 12, 2003, suggest that some 
of this frustration might have been alleviated if the EOCs had received the FRMAC analysis 
products sometime during the first night of the FSE. In a conference call at 2000, the PFO 
assured the State and local officials that the DOE would provide them with AMS data once they 
were received and analyzed. However, as described in the reconstruction, it took longer than the 
PFO expected for the FRMAC to complete the analysis of the AMS data; the analysis products 
were not completed until after the JOC closed for the night. This exercise artificiality may have 
led to, or possibly exacerbated, frustrations because local and State officials then had to wait a 
minimum of eight hours to receive the information they needed. 

Although the JOC re-opened at 0700 on May 13, 2(X)3, the FRMAC did not deliver their 
deposition map to the Seattle or WA State EOCs until mid-day on May 13. As a result of not 


The evaluation team does not know wheiher Seattle EOC or incident command were plotting data in a similar 
manner, or whether the various EOCs shared their deposition maps. 


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having the advance party meeting on May 12, 2003, the FRMAC did not have the appropriate 
contacts within the various EOCs. If the FRMAC had the contact information and the clearance 
to provide maps directly to Seattle, King County, and WA State EOCs, the FRMAC might have 
supplied them with the deposition data product map as early as 2330 on May 12, 2003. It is 
highly likely that had the JOC remained open throughout the night, the FRMAC would have 
received clearance to distribute the deposition maps and would have identified the appropriate 
contacts at the Seattle, King County, and State EOCs, as each jurisdiction provided liaisons to 
the JOC. 

It appears that after the FRMAC deposition maps were distributed to State and local EOCs, there 
was less confusion over which information to use for decision-making. The distribution process 
was flowing well by the end of play on May 13, 2003, and continued rather effectively on May 
14, 2003 — at least in Washington State. Regionally, the players' were well aware of the 
problems, and found ways to resolve them. However, the concerns in Washington, D.C., did not 
seem to end. even after the exercise was 
over. Nonetheless, there is no evidence that 
activities at the Federal inter-agency level or 
the different data products provided to the.se 
top officials had any impact on the response 
in Washington State. 

6. Conclusions 

Several lessons can be learned from the data 
coordination and analysis product 
distribution challenges faced by responders 
and top officials in Washington State and 
Washington. D.C. Plume models provide a 
prediction of where the material in the 
explosion will travel. They can be useful in 
assisting decision-makers in making 
preliminary decision regarding likely areas 
of contamination. Once actual data from the 
incident are collected and evaluated, the 
value of plume models diminishes. Once 
responders learn what really is out there and 
where it is, predictions alone become less 
important. However, predictions updated 
with initial measurement data can be useful 
in estimating protective actions in areas that 
have not yet been surveyed, or in areas that 
have been contaminated below the 
measurement threshold of available 
instruments. During the FSE, WA State 
DOH and Federal SMEs could have 
provided top officials with this information. 

Additional educational opportunities might 
have been available in many months leading 


SuMMARV OF Conclusions — 
Data Collection and Coordination: 


On-siie and off-siie data coordination during the FSE 
was minimal at best. As a result, no one agency at 
the incident site had a complete operational picture, 
and multiple agencies were performing redundant 
tasks. The development of National Incident 
Management System may help to facilitate the data 
collection and coordination processes in the future. 

There was much confusion during the FSE about the 
multitude of plume prediction maps among agencies 
and across jurisdictions. While it did not happen 
during the FSE, if agencies and jurisdictions produce 
inconsistent and conflicting maps, the media could 
question the governments' credibility and ability to 
make decisions. 

Officials at all levels of government need to be 
educated about the differences between plume 
dispersion prediction models and data products 
generated from empirical data. Officials need to be 
aware of how each can aid decision-makers and the 
limitations of both. 

FSL agencies and departments should be educated 
about the need to coordinate the data collection and 
distribution processes and the implications of a lack 
of coordination. 

Plans and procedures for radiological incidents were 
initially developed for emergencies at nuclear power 
facilities. To be effectively applied to terrorist 
events, these plans and procedures may need to be 
modified. 

On-site data collection may also benefit from the 
designation by the Incident Commander of a support 
agency to lead the coordination effort. 


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up to the FSE. 

On-site and off-site data coordination was minimal at best. For SMEs to develop the most up-to- 
date information and provide the highest quality recommendations, it is critical that they receive 
data collected from all relevant locations. During the T2 FSE, the coordination to send all of the 
data to one place was lacking. One aspect of the response that became clear during the FSE was 
that there are many as.sets with radiological data collection capabilities at FSL levels of 
government that need to be accounted for in the data collection process. In planning responses to 
terrorist attacks, procedures need to recognize all of the possible responders, and wof^o ensure 
that they are coordinating effectively. The development of the National Incident Management 
System (NIMS) may help to facilitate the data collection and coordination processes^m- the 
future. 

In addition to the FRMAC, many State and local government agencies have their own 
capabilities and responsibilities to generate plume predictions and depositimi maps. In an 
emergency, State and local governments are likely to rely on their assets before Federal 
assistance arrives, and to continue to rely on them throughout the response and recovery. The 
Federal Government cannot prevent other FSL agencies from using their own models and 
developing their own predictions for internal planning purposes. However, FSL agencies and 
departments can be educated about the importance of centralizing the data collection and 
analysis product distribution processes and learning to work with the FRMAC to coordinate 
efforts during radiological emergencies and th^c6ns^uences if that does not happen. 




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E. Play Involving the Strategic National Stockpile 


1. Introduction 

In Illinois, during the Top Officials (TOPOFF) 2 (T2), the anival, breakdown, distribution, and 
dispensing of the Strategic National Stockpile (SNS) was played in unprecedented detail during 
the Full-Scale Exercise (FSE). It culminated in the 
dispensing of thousands of doses of simulated 
medication to role players at five separate sites, in 
five jurisdictions. However, perhaps of even greater 
interest than the actual distribution were the 
discussions and decisions leading up to the 
distribution activities. Officials had to determine: 

• How to request the SNS; 

• Who should receive the medications; 

• How much was available; 

• When and where to distribute it; and 

• How to announce it to the public. 

This account focuses on how the local municipalities dealt with the issues of providing 
prophylaxis to both first responders and the public, li also examines decisions made about the 
SNS at the inter-agency level. 

2. Background 

Created in 1999, the SNS is a national repository of medications and other supplies and 
equipment that can be deployed in the event of a terrorist attack. Formerly known as the 
National Pharmaceutical Stockpile, the SNS was renamed upon its transfer to the Department of 
Homeland Security (DHS) in 2003, The SNS is a multi-agency resource, with responsibilities 
split across DHS. the Department of Health and Human Services (HHS), and the Veterans 
Administration. According to a recent Memorandum of Agreement among the three 
departments: 

The DHS Secretary shall, in coordination with the HHS Secretary and the 
Sedreiary of Veterans Affairs, maintain the Strategic National Stockpile. 

The DHS Secretary shall he responsible for the overall strategic direction, goals, 
objectives, and performance measures for the Stockpile. 

The DHS Secretary shall be the owner of the Stockpile and the a5.sets (excluding 
personnel) of such Stockpile shall transfer to the DHS Secretary. The Stockpile 
shall remain in the physical custody of the HHS Secretary until deployed by the 
DHS Secretary. 

The DHS Secreta)y. in consultation with the HHS Secretary, shall direct the 
deployment of the Stockpile, determine pre-position locations and shall have the 
responsibility for authorizing the transfer of custody of Stockpile contents to State 
or local authorities. 



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However, while giving ownership of the stockpile to DHS, the Memorandum of Agreement 
assigns management responsibilities to HHS: 


In consultation with the DHS Secretary, the HHS Secretary in managing the 

Stockpile shall determine for the Stockpile the appropriate and practical numbers, 

types, and amounts of drugs, vaccines, and other biological products to provide 

82 

for the emergency health security of the United Slates. 


The Centers for Disease Control and Prevention (CDC) maintains the SNS within HHS. 


The SNS consists of two parts: the 12-hour push package (push pack) and Vendor Managed 
Inventory (VMI). CDC maintains 12 push packs strategically distributed at ten sites around the 
nation. Upon release by the CDC, the SNS can deliver a push package to the site of an 
emergency in 12 hours or less. Thus, it can be deployed before the specific infectious agent has 
been confirmed. Each push pack contains more than 50 tons of supplies. Depending upon the 
infectious agent, a push pack can treat from .several thousand to several hundred thousand 
people. In a large bioterrorism incident, the VMI can also be deployed. It'.s tailored to contain 
the specific medications to treat victims of a known agent. The VMI can arrive in the affected 
area within 24 to 36 hours. Either the VMI or the push-packt^e can be shipped first, depending 
on the situation. 

Illinois also maintains its own pharmaceutical stockpile, known as the Illinois Pharmaceutical 
Stockpile (IPS), and some localities maintain stockpiles of medications. The IPS is 

designed for use by immediate responders.*‘^„^se of [these stockpiles was also played during the 
FSE. 


3. Recoastruction 
a. Overview 





The SNS Operations Center (SNSOC) was activated at 1500 EDT May 12, 2003, based upon a 
directive from DHS. In a conference call at 2000 EDT, HHS Secretary’s Command Center 
(SCO directed that two SNS sites nearest^to Chicago be readied for loading onto planes. It is 
not clear, however, whether the SNSOC received this directive. The SNSOC did receive a 

/ r 

directive from DHS to pre-d^loy a push package to the Chicago area, which it did. The City of 
Chicago, followed closely by^he State of Illinois, requested the SNS early on the afternoon of 
May 13, 2003, immediately after a bioterrorism incident involving the release of Pneumonic 
Plague was confirmed. The next morning, officials publicly confirmed that there had been a 
relea.se of plague at the United Center, O'Hare International Airport, and Union Station, and only 
at these three sites. At 1025 Central Daylight Time,*^ the push pack arrived at O’Hare. It was 
distributed to the local jurisdictions that afternoon, after which most jurisdictions issued 
prophylaxis to their first responders. The follow-on VMI supplies began to arrive at 1937 on 
May 14, 2003. The distribution .sites were opened to the target population at 0800 on May 15, 
2003, at the same time that the Virtual News Network (VNN) announced the distribution 


Memorandum of Agreement between the Department of Health and Human Services ajid the Department of 
Homeland Security concerning cooperative arrangements to prevent, prepare for, and respond to terrorism and major 
disa.sters, signed February 28, 2003 and March 5, 2003. 

Illinois Department of Professional Regulation State Board of Riarmacy, [Newsletter] Feb 2003. 

All times provided are Central Daylight Time, unless otherwise noted. 


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locations and listed the target population. Figure 15 depicts the timeline of events related to the 
request for and distribution of the SNS. 

Strategic National Stockpile 


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Figure 15. Timeline of Event!; Related the SNS 
b. Initial discussions 

Decisions and activities relating to the SNS took place at all level.s of government. On the 
morning of Ma>' 13, 2003, before diagnosis of plague, discussions began at local and Stale 
deparimenlfi of public health (DPHs) about the need to provide prophylaxis and to request and 
activate pharmaceutical stockpiles — local, stale, and national. The SNS also came up in 
di.scussions at the Federal Emergency Management Agency (FEMA) Region V Regional 
Operations Center (.ROC); the HHS Region V Regional Emergency Operations Center (REOC); 
the County. City, and State Emergency Operations Centers (EOC); HHS Headquailers; DHS 
Headquarters; and the Strategic Information Operations Center (SIOC) in Washington, D.C.; and 
the CDC in Atlanta. 

HHS had already alerted CDC to have the SNS ready to go. On May 12, 2003 at 1900, 
anticipating u rise in the threat condition to Red. HHS directed CDC to put the .stockpile on 
planes, with the two closest to Chicago ready to go. At 1946. having heard that threat condition 
was raised to Red in seven cities, the HHS Assistant Secretary Public Health Emergency 
Preparedne.ss told his staff to notify CDC to load the planes — a standard operating procedure for 
the CDC upon Red being declared. 


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At 0800 on May 13, 2003, CDC reported that the SNS was being deployed to Chicago. At 1030, 
the CDC Director reiterated public health priorities. One of these was to focus on the immediate 
needs of Chicago, as well as Seattle which had just experienced the detonation of a radiological 
dispersal device (RDD), but not to over-commit CDC resources, as there was a potential for 
multiple terrorism events in other parts of the country. In an 1 100 conference call with HHS, the 
ROC. and the REOC, CDC reported that the SNS could be delivered to Chicago within an hour. 
At 1228 the Chicago, Illinois Department of Public Health (IDPH) lab recorded a positive 
Polymerase Chain Reaction (PCR) test for plague. However, it wasn’t until 1415 that CDC 
received notification of the positive PCR; at that same time the confirmation of plague was 
announced on VNN. 

On May 13, 2003, at 1730 EDT, HHS Secretary Thompson declared a public health emergency 
in the City of Chicago, allowing HHS to provide federal health assistance under its own 
authority. 

c. Reque.sting the stockpile.s 

In Illinois during the afternoon of May 13, 2003, local jurisdictions and the state declared a state 
of emergency and requested the SNS. There was some confusion as to when declarations were 
officially declared by the individual jurisdictions. At 1253, the FEMA ROC log noted that the 
City of Chicago was requesting the SNS; a similar entry regarding an urgent request from the 
state was logged at the ROC at 1325. Discussions about requesting the SNS occurred at the 
DPHs starting about 1330. At the DHS Crisis Action Team (CAT) at 1430, there was discussion 
of deploying the SNS. A request from the City of Chicago for a push pack showed up in the 
Department of Homeland Security (DHS) Homeland Security Center (HSCenter) at 1528 and at 
the CDC around 1600. 

At 1 250, VNN aired footage of the Illinois Governor reporting that that he had declared a state of 
emergency in Illinois, requested a disaster declaration from the President, and requested delivery 
of the SNS. At 1410 the Illinois Operational Headquarters and Notification Office (lOHNO) 
reported that the Illinois State EOC would request the SNS (push pack and VMI) through the 
Governor’s office; at the same time Cook County DPH checked with the state for procedures. 

At 1515, IDPH notified the SEOC to ask for surgical masks and ventilators as part of the VMI 
request. Later that afternoon, in a conference call at 1655, discussion ensued about procedures 
for requesting the SNS. IDPH went directly to CDC, whereas the Illinois Emergency 
Management Agency (lEMA) went to the ROC. On May 14, 2003, at 0935, lOHNO logged 
specific requests from the VMI for Doxycycline, Ciprofloxacin, masks, and ventilators. 

d. Who should receive antibiotics 

Internal debates about a prophylaxis distribution policy for first responders, including non- 
governmental organizations such as the American Red Cross, and the public occurred in all local 
jurisdictions. These discussions were necessitated not only by the enormous logistical 
challenges of distributing medications to a metropolitan area whose population exceeds seven 
million, but also by the very real limits of the amount of medication that was immediately 
available. 

In the end, all jurisdictions except Chicago decided to provide prophylaxis to all first responders. 
Chicago was unable to do this due to the sheer size of their first responder population, estimated 


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at 96,000, and because officials felt it would be politically untenable to provide medications to 
all of the first responders before the providing the same for the general public. 

The distribution of simulated local pharmaceutical stockpiles was demonstrated in Chicago and 
DuPage County. Chicago DPH administered prophylaxis from its own stockpiles to Chicago 
DPH staff (on May 13, 2003, at 1640). DuPage County followed its protocols and administered 
its stockpile to its first responders and their immediate families (a decision made at 1326 on May 
13, 2003) and County employees (distribution began at 0914 on May 14, 2003). 

Within the Lake County EOC, there was a discussion as to how many people in each category 
should receive prophylaxis. They also discussed who would make the decision about how many 
people to provide prophylaxis for. In the end, they decided on all first responders per protocol. 

Both Cook County and Lake County issued prophylaxis to first responders at 1600 on May 14, 
2003: it is unclear whether they used the IPS or the SNS. Chicago, however, issued medications 
to a single shift of first responders only: those on duty during the earty morning hours of May 15, 
2003. They did not distribute the antibiotics earlier due to a miscommunication; they believed 
that all jurisdictions had agreed to delay distribution of the SNS to anyone until 0800 on May 1 5, 
2003. Chicago learned that the other counties had already distributed to first responders via an 
email at 1926 on May 14, 2003, stating that all Cook County first responders had received 
prophylaxis. At that point they began to make plans to do their own, partial distribution to first 
responders. At 2039 on May 14, 2003, a broadcast fax advised the Chicago district watch 
commanders to pick up prophylaxis packages; they were distributed to police officers beginning 
at 0032 on May 15, 2003. 

As far as prophylaxis for the general public, there was also a city/county divide. The counties 
initially decided to offer prophylaxis to their entire communities. Chicago, again, differed. In a 
conference call at 1300 on May 14, 2003. the counties and IDPH discussed the situation. That 
morning, the plague outbreak had been publicly linked to three locations: a terminal at O'Hare 
International Airport, the United Center, and Union Station. Ultimately, all realized that a 
common policy had to be adopted to prevent one Jurisdiction from potentially being overrun by 
citizens of another that had decided upon limited distribution. That realization was helped along 
by a recommendation from IDPH, which called for a distribution targeted at the following: 

• People who were in the United Center. O'Hare Terminal 3**^, or Union Station on May 
10,2003; and 

• People who had household contact with any presumed or diagnosed cases. 

Although some of the counties were unhappy with this policy and discussed overriding the 
decision, all eventually agreed to it. 

Later that afternoon, at 1445, lOHNO noted that IDPH recommended and the counties concurred 
that an individual could pick up medications for other family members if he/she provided the 
required information. 

Chicago’s final decision, based upon a Chicago DPH recommendation, was announced at a 1730 
EOC briefing: the first people to receive antibiotics were those in contact with cases, attendees at 
the venues, and first responders likely to be in contact with contaminated people (those on shift 


The release was later determined by consensus to have been Terminal 2, not Terminal 3. 


95 




when the drugs were distributed). They anticipated a quick backfill of antibiotics for the 
remaining first responders and their families. 

e. How much was available 

Confusion and contradictory information complicated officials' decision-making. First was the 
difficulty of determining the amounts in local stockpiles. Second were the issues about how 
much the state had and how the medication would be allocated. Finally, there were questions 
about how much would come from the SNS, when it would arrive, and how much each 
jurisdiction would receive. 

An account of the confusion is documented here, focusing on the largest jurisdiction, the City of 
Chicago: 

At 1715 on May 13, 2003, Chicago HOC requested 1.1 million doses of prophylactic antibiotics 
from lEMA, including 96,000 for first responders. Other jurisdictic«s requested lesser amounts; 
for example. Lake County requested 15,000 for its first responders and their families. 

During a conference call starting at 1730, which included the FEMA ROC, lEMA, IDPH, and 
Chicago Office of Emergency Management (OEM), the OEM Director asked how many doses 
would be coming. lEMA replied, “enough, and will continue to re-supply.” The city pressed for 
a number. lEMA said it was still determining the number. Chicago asked if this would be an 
open faucet, noting that its distribution schedule would depend upon the number of doses 
received. The ROC replied that the supply didn't seem to be a problem. Shortly thereafter, at 
1818, the Chicago OEM director reported to his staff that the city was getting one million doses. 

On May 14, 2003, IDPH decided that the stockpile would be broken out by jurisdictional 
populations. The IDPH Chicago office came up with these numbers for the initial distribution (a 
total of 45,800 doses*^^) for the entire region; 

• City of Chicago 12,400 doses 

• Cook County 12,500 doses 

• DuPage County l0,5(X)doses 

• Lake County 6,000 do.ses 

• Kane County 4,400 doses. 

At 0917, the county health departments received a fax with these numbers. 

About an hour later, however. Chicago DPH reported to the EOC that lEMA and IDPH said the 
city would receive 30,000 from the Illinois stockpile and 30,000 from the SNS. The Chicago 
DPH reported this again at 1 150. They were expecting 60,000 doses available for Chicago. 

At 1030, the Chicago OEM requested clarification during a conference call that included lEMA, 
the IL State EOC, and the Joint Operations Center (JOC). lEMA replied that the city would get 
30,000 from the IPS and 12,400 from the SNS. However, at 1154 IDPH told Chicago DPH that 
the total of IPS and SNS doses was 30,000. 


It is not clear whether by “doses” they meant regimens (i.e. pre-packaged 10-day treatment courses). Each push 
pack contains pre-packaged regimens of Ciprofloxacin and Doxycycline. 


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The crisis over amounts of antibiotics available was definitively over at 1937 on May 14, 2003. 
At that time the IL State EOC announced in an exercise inject that VMI had arrived and that 
local health departments and hospitals would continue to be supplied for the length of the event. 

The lack of clarity over available amounts illustrated by the above sequence of events can at least 
partially be traced to agencies sometimes co-mingling state and federal supplies, and also to a 
failure to separate out, in number and timing, the relatively small amounts in the push pack 
compared to the continuing flow of VMI. 

f. When and where w'ould the supplies be available 

At 1730, on May 13, 2003, during a teleconference between FEMA, CDC, lEMA, and the 
governor’s office, it was announced that the SNS would arrive at 1000 on May 14, 2003. 

According to an exercise inject, the stockpile arrived at O’Hare airport at 1025 on May 14, 2003. 
It was transferred to a warehouse at 1055, at which time CDC signed it over to local authorities. 
The supplies were broken down and started arriving at the jurisdictions at 1330. Jurisdictions 
had pre-planned sites for distribution of the SNS to the target population, and an agreed-upon 
time for opening them. The distribution sites opened to the public at 0800 on May 15, 2003.''" 

g. How were these decisions conveyed to the public 

The public was informed that the SNS was available if needed by the Assistant Secretary Public 
Health Emergency Preparedness in HHS. At 1322, on May 13, 2003, the Secretary reported via 
VNN that the SNS was in the Chicago area and ready to be deployed. At 1527, VNN reported 
that the SNS was being rushed to Chicago. 

A press release from the Office of the Governor early during the afternoon of May 13, 2003, 
indicated that antibiotics from the SNS would be distributed by local health departments to those 
with symptoms or those exposed. People with symptoms were told to go to the nearest hospital. 
Those exposed to the symptomatic were told to receive antibiotics. 

In a press conference at the Joint Information Center (0930 on May 14, 2(X)3), the three release 
sites, O’Hare International Airport, Union Station, and United Center, were confirmed. 

On May 14, 2003, at 0940, lOHNO suggested on VNN that anyone who was at the three release 
sites should get prophylaxis. In a 1030 press release from the Governor’s office, the Director of 
IDPH gave the same advice. At 1230 on May 14, 2(X)3, the DHS Secretary on VNN advised all 
employees at the three sites to go to their doctors to get antibiotics. Chicago DPH, however, 
issued a press release stating “insisting that all Chicagoans stay at home until further notice, 
except for those adults considered to be essential to public safety.. ..[and] those experiencing 
symptoms ” 

At 1259, on May 14. 2003. VNN announced that the SNS had arrived in Chicago. 

At 1345, VNN announced that only 30,0(X) doses were coming to the Chicago area, whereas at 
1745, a HHS official on VNN stated, “Once the faucet is turned on, the flow [of medication] 
doesn’t stop.” 

At 1407, on May 14, 2003, there was a conference call that included the JOC, as well as the City 
and State EOCs about how to use the media to encourage people to stay home instead of rushing 

The Lake County site opened at 0832. 


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to the distribution centers. The message would be: “Stay home unless you’re in the exposed 
target groups; otherwise, going to the distribution site will increase your risk of infection.” 

At 1425, in a conference call between lOHNO and CDC, consensus was achieved that a release 
would be issued that evening stating that distribution sites would be made public on the morning 
of May 15. 2003. 

At 0800 on May 15, 2003, VNN issued details on distribution, identifying the locations and the 
target populations, including a change in who should go for medications. Symptomatic people 
were told to seek medical attention. Persons exposed to people with symptoms, those who had 
been at the three release sites, and those exposed to them were advised to go to their local 
distribution center. 

At 0830 May 15, 2003, VNN reported that SNS had plague treatment for 115 millioa people. 

4. Artificialities 

None of the pharmaceutical stockpiles were actually deployed. SNS provided their training, 
education, and display package at the request of Illinois State to allow IlUnois to test its ability to 
receive and distribute a push package. It is an exercise artificiality that the push packages were 
deployed at all. In a real event, the SNS reaction to requests for SNS would have been to send 
VMl, since pneumonic plague was already Identified. It is unclear what the public reaction to 
the targeted distribution scheme would have been'**. 

For reasons of space availability, the T2 scenario required that the SNS to arrive on the May 14, 
2003, and be distributed at 0800 on May 15, 2003. This .schedule gave decision-makers the 
luxury of time to discuss and determine in concert how to distribute the medications, and they 
didn't even have to coordinate the time of distribution; it was given to them, in real life, 
pressures for a faster distribution would have made such coordination more difficult. With a 
compressed timeline and during a real emergency, jurisdictions might have made different, 
independent decisions and chaos could have been the result. In fact, discussions during this time 
period in the HHS SCC indicated continuing concern about the delays in opening the distribution 
centers. 

Ultimately, the VMI was declared sufficient for the State’s needs. The health departments 
discussed offering mass prophylaxis after they were told that the amount of antibiotics was no 
longer an issue. 

5. Analysis 

The SNS story spans five of the areas of analysis and the inter-agency and Illinois venues. It is 
first and foremost the story of emergency public policy and decision-making regarding the 
allocation of a .scarce resource. It involved jurisdictional issues at the Federal and local levels. It 
is also the story of local jurisdictions coming to separate decisions and then coordinating them 
(with some help from the state) to reach a common policy. Successful distribution required a 
coordinated, well-thought-out and accurate public information campaign. 


** Dr. Henry W. Fischer. Ill, in his btxrk, “Response to Disaster: Fact Versus Fiction and Its Perpetuation — The 
Sociology of Disaster,” predicts that panic would not ensue in a biolerrorisin attack, but there is thankfully no data to 
draw upon to validate this prediction. Dr. Fischer does not specifically address the complications that could arise 
with the distribution of prophylaxis. 


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a. Decision-making 

The key decisions regarding the SNS were who should get the antibiotics and in what order. To 
make those decisions, officials needed different types of information: 

• Which antibiotics would be effective; 

• How quickly would they need to be administered; 

• How much was available; 

• How long would it take to get the antibiotics; and 

• How quickly could they be re-supplied? 

During the FSE, decision-makers received conflicting information regarding the amount of 
antibiotics in the stockpile. Knowing the answers to the following questions would help officials 
better plan their strategy for distribution: 

• Was there enough medication to provide prophylaxis to all first responders or would 
it need to be done in stages; 

• If done in stages, would it be best (or possible) to provide prophylaxis to all those on 
duty and keep them on duty until sufficient .supplies arrived for the rest; 

• Or would it be better to give partial courses out to all first responders so that all could 
get started and then receive the rest of the course as more supplies became available; 
and 

• How many sites should be set up for distribution to the citizens, considering the 
tradeoff between number of distributors (who also need prophylaxis) and number 
served? 

Decisions made by the City of Chicago typify the importance of good information. Chicago, 
with its huge population, was the most hard-pressed jurisdiction.’*'' It requested 1,063 million 
doses and waited for information from the state as to how much they would actually get. The 
state came back and said they could have 40,000 doses; however, it ended up with only 12,400. 
The city made distribution plans based on the 40,000 number. It chose not to provide 
prophylaxis to all first responders before reaching out to the public because it was concerned 
about adverse public reaction. Chicago decided instead to take a parallel approach, giving 
medications to current shifts of first responders, and at the same time providing medications for 
people who were at the three venues and the primary contacts of symptomatic patients. It is not 
clear if the city could actually have accommodated all of these p>eople with the medications 
available to them at the time. 

b. Resource allocation 

The various pharmaceutical stockpiles constituted a scarce resource, at least until the VMl 
portion of the SNS began flowing. Some of the local Jurisdictions had their own stockpiles, 
which they used to provide prophylaxis to different parts of their population: Chicago DPH gave 
antibiotics to its own staff; DuPage County administered its supply according to its phased plan. 


39 


Cook County is almost equally large, but less data was available on their decision-making. 


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providing medication to first responders and their families and County staff and their families. 
The other jurisdictions apparently did not have their own stockpiles. 

These differences raise policy issues. If some jurisdictions have their own stockpiles, should that 
be taken into account in allocating the supplies from other stockpiles? Such calculations 
appeared not to have been made, as the amounts provided to the localities from the state and 
local stockpiles were based upon population. 

In addition, if the state issues guidance to medicate only first responders in advance of the 
general public, can a locality provide antibiotics to other segments as well out of its own 
stockpile? Would it then receive less from state and national stockpiles? Questions such as 
these become increasingly relevant as States and localities debate the advisabiliQ' of establishing 
local stockpiles, given the difficulty of maintaining them.'*^ 

c. Emergency public information 

Public information play regarding the SNS had successes and failures. Some pronouncements 
were made that could have caused .some measure of concern and confusion among the public. 
Several of these may have been due to erroneous VNN statements and not inappropriate 
judgments on the part of the officials releasing the information. However, a story such as the 
one describing the 30, 000 do,ses that would be coming to Illinois (when originally there was 
believed to be 60,{M)0 doses) could have caused chaos at medical facilities. And early 
recommendations from lOHNO. IDPH, and HHS that people at the release sites should obtain 
prophylaxis could have caused serious problems.^' Tliese were made before the SNS had arrived 
and distribution sites had been set up. Tens, if not hundreds, of thousands of people who fit that 
description could have descended en mas.se upon medical facilities and pharmacies to get 
antibiotics that were not yet available. However, this problem is, at least in part, an exercise 
artificiality, as the consensus is that SNS play was artificially delayed. 

In addition, conflicting advice was given about staying home and going out to get prophylaxis. 
Whereas lOHNO, IDPH, and HHS recommended that people at the venues obtain prophylaxis, 
Chicago DPH went on record “insisting that all Chicagoans stay at home until further notice, 
except for those adults considered to be essential to public safety.. ..(andj those experiencing 
symptoms.” 

The crafting of a joint press release about the SNS distribution at 0649 on May 15, 2003 was 
crucial to the success of the distribution and ultimately to containing the plague. Officials had to 
do their best to draw out those people who needed prophylaxis, while discouraging those who 
didn't from coming out and taking the limited supplies and/or unleashing unrest at the 
distribution sites. They agreed not to release the SNS distribution locations until the morning of 
May 15. 2003, to minimize the potential for civil unrest and chaos at the distribution sites. The 
release described who should seek prophylaxis (those at the release sites on the dates indicated, 
and those within six feet of someone displaying symptoms); where they should go; and when 


^ In June 2002, then IDPH Director John Lumpkin spoke again.st k)cal stockpiles. When DuPage County asked 
about receiving reimbursement for the thousands of dollars it had spent on its stockpile, the Director of IDPH replied 
that, “Counties should not keep individual stockpiles because Illinois has an arrangement with a pharmaceutical 
company that keeps a current supply available that could be distributed to a county within a short period of time” 
[from the minutes of a DuPage County Board of Health meeting (6 June 2002)]. 

In the HHS statement, employees were singled out in the recommendation to receive antibiotics as they were 
presumed to have been exposed for a longer period. 


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they should arrive. It dissuaded those who hadn’t been exposed from coming by reminding them 
that they would be safer at home, and stated that people with symptoms should go to the hospital, 
not the SNS sites. 

However, this press release contained a flaw: it miss-stated one of the plague release sites. 
Confusion persisted throughout the FSE about which terminal was the release point at O'Hare 
International Airport. At various times, it was called Terminal 2, Terminal 3, and most 
frequently the International Terminal, which is Terminal 5. On May 14, 2003, around 1000, 
consensus was reached among public health departments that Terminal 2 was the correct 

terminal (which it was), but this information apparently was not passed on. When announcing 

who should get prophylaxis, the press release listed the international terminal as one of the three 
release sites. This may have been in part an exercise artificiality, as the myriad of reporters who 
would have covered this incident in real life would presumably have identified the discrepancies 
in public statements. But had they not, thou.sands of potentially exposed individuals could have 
been without drugs. 

In addition, press releases about the SNS on May 14 and 15, 2003, contained conflicting 
information on the target population. There were several sets of somewhat differing guidance. 
The first concerned the dates of exposure. There were three variations: 

• People who were at the sites on May 10, 2003; 

• People who were at the three sites from May 10 to May 13, 2003; and 

• People who were at the United Center from May 10 to May 14, 2003. 

The second set concerned the description of who would receive prophylaxis. This set contained 
both internal inconsistencies and differences among jurisdictions. There were two variations. A 
press release from the DuPage County Board at 181 1 on May 14, 2003, listed those exposed at 
the sites or those exposed to people with symptoms, and their entire families; however, this 
release also stated: “only people who have had direct close contact with infected patients should 
obtain antibiotics.” A Chicago DPH press release at 0651 on May 15, 2003, listed those who 
were exposed at the sites and their close contacts, but only those household members who had 
been exposed to a person with symptoms. It’s unclear whether these statements were actually 
released and whether the differences in them represented differences in distribution policy or not. 

d. Coordination and communications 

As noted earlier, miscommunication among the local jurisdictions caused the Chicago OEM to 
delay prophylaxis to its first re.sponders while the counties went ahead with theirs. Had this 
played out in real life, it might have caused serious problems with the Chicago first responder 
communities. The Chicago OEM believed it had been told during a teleconference that none of 
the Jurisdictions were distributing any prophylaxis until 0800 on May 15, 2003. This had 
financial repercussions as they had planned to dispense to first responders that evening; 
consequently, Chicago had police officers earning roughly one million dollars in overtime pay 
and doing nothing. When the OEM found out via routine e-mail that other jurisdictions had 
completed their first responder prophylaxis in the late afternoon of May 14, 2003, it put into play 
a partial distribution to first responders later that evening. 

This misunderstanding can be traced to the medium of the conference call. Without written 
documentation of decisions reached, the potential exists for miscommunication. This was 


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observed throughout the FSE. During many teleconferences, roll calls were not taken, and it was 
unclear as to who was on the teleconference. In addition, on several instances different people 
heard different things and reached different conclusions about the outcome of the calls. 

The conference call was useful as a means of coordination among agencies located far from one 
another and scattered among the EOCs. However, it was far from ideal as a reliable means of 
communication. These issues in the public health community were observed in TOPOFF 2000 
as well, and were cited by the General Accounting Office in its September 2000 Report to 
Congressional Requestors titled, “West Nile Virus Outbreak: Lessons for Public Health 
Preparedness,” and in which many officials reported problems in this area as the investigation 
into the outbreak grew. These problems could be ameliorated through strict adherence to roll 
call procedures and by designating one party to document any decisions reached and distribute 
them rapidly back to the participants via e-mail for confirmation. 

e. Jurisdiction 

The procedures and processes for requesting and receiving the SNS were a source of confusion 
throughout the exercise. Different jurisdictions took different routes to request this resource, and 
different agencies in the State also pursued their own paths. IDPH went directly to CDC, 
whereas lEMA went through the FEMA ROC; both of these are acceptable channels to request 
the SNS.’^'^^ It is unclear precisely what initiated the flow of prophylaxis. The two directives, 
one from DHS and another from HHS, regarding the deployment of the SNS provide one 
example of a jurisdictional challenge raised after the creation of DHS. 

As noted in the background .section, responsibility for this resource is shared between DHS and 
HHS. According to the Memorandum of Agreement, the decision to deploy the SNS is made by 
DHS in coordination with HHS. During the FSE. both HHS and DHS were giving directives 
regarding activation and deployment of die SNS. The SNSOC coordinated the stockpile 
deployment with the CDC and the FEMA EP&R Director. There is no data to indicate that 
senior-level consultation occurred between DHS and HHS. This issue was complicated when 
HHS declared a Public Health Emergency, which would allow it to deploy resources on its own 
authorities and at its own cost. 

The following questions specific to the SNS were brought out during the course of T2: 

• What is the process for requesting pharmaceuticals from Stale and Federal stockpiles; 

• Does each jurisdiction have to submit its own request; 

• Through whom do they issue the request; 

• Can they request from multiple sources; and 

• How much does one jurisdiction’s request affect those of others? 

The question of process arose despite the fact that there is a well-defined process for requesting 
the SNS (that should be a part of every public health agency’s SNS distribution plan per CDC 


It would be useful for DHS and HHS to clarify policies on how to request the SNS and educate the states on these 
procedures. 

Jurisdictional issues related to the SNS are discussed further in the Core Area on jurisdiction. 


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guidance). The official process involves a request from the governor or the mayor to the CDC, 
which then consults with DHS. There is no requirement for a disaster or emergency declaration. 

6. Conclusions 


The SNS was extensively exercised during the 
FSE. Local jurisdictions tested their ability to 
distribute supplies of antibiotics to their first 
responders and citizens. The state tested its 
ability to break down and secure the antibiotic 
stocks. Receipt, breakdown, distribution, and 
dispensing were completed successfully. But 
the SNS problem was far greater than the 
physical breakdown and dispensing of the push 
pack. It tested the ability of all levels of 
jurisdictions and agencies to make decisions, 
allocate resources, coordinate and communicate, 
and inform the public. 

It is clear that work remains to be done in all of 
these areas. Pressures to make decisions under 
emergency conditions and tight timelines can be**' 
partially alleviated through thorough 


Rre- 

planning and advance coordination amongstv 
jurisdictions. The challenge is to figure out in^' 
advance the procedures for getting good 
information, sharing it widely, and malang*and I 
documenting decisions in a coordinated/way^H 
when operating under severe time pressure. 

V 


SUMMARY’ OF CONCI-USH)N.S — 
Strateoic National Stockpile (SNS): 


Overall, the receipt, breakdown, distribution, and 
dispensing of ihe SNS during the FSE were 
completed successfully. 

The SNSOC coordinated the stockpile 
dcpioymeni wiih the CDC and the FEMA 
EP&R Director; there are no data to indicate 
that senior-level consultation occurred between 
DHS and HHS. 

Mi.scommunication among local jurisdictions 
caused Chicago OEM to delay prophylaxis to 
its first responders while the counties went 
ahead with theirs. 

Different agencies chose different avenues to 
request the SNS; this was a source of confusion 
throughout Ihe FSE. 

Conflicting and confusing information was given 
to the public regarding who should seek 
prophylaxis and when, the plague release sites, 
and whether one should slay home or seek 
medical attention. 



V 


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F. Hospital Play in the Illinois Venue: Resources, Communications, and Information 
Sharing during a Public Health Emergency 


1. Introduction 

In the event that a highly contagious and lethal disease is spreading 
throughout a population, hospitals and other health care providers will 
become the first line of defense against a large-scale health 
catastrophe. How hospitals work with each other and the State and 
local public health authorities is critical to determining whether they 
will be successful in caring for patients and limiting the spread of the 
disease. Top Officials (TOPOFF) 2 (T2) presented an unprecedented 
opportunity to examine the coordinated efforts of the medical and 
public health communities to react to and control the spread of a 
disea.se outbreak. Because of the large number of participating 
hospitals, communication and resource requirements were significant. 

During the T2 Full-Scale Exercise (FSE) an outbreak of Pneumonic 
Plague was simulated in the Illinois venue. Hospitals from thoCity of 
Chicago and the surrounding region participated in the exercise by receiving patients, and 
sharing information about resources. Hospitals coordinated, or needed to coordinate, in the areas 
of staffing and personnel, patient accession, the numbers and types of disease cases, diagnostic 
and treatment information, and diagnostic and treatment resources. 

Hospitals used a range of technologies to share information about patients and re.sources. These 
technologies included fax, voice. Internet, phone hotlines, and call trees, 

This special topic examines two critical issues surrounding hospital play during the FSE: 

• How the hospitals communicated resource and patient infonnation during the exercise; 
and 

• What resources the hospitals had available to respond to the outbreak. 

2. Background 

In the Illinois venue**^ 64 hospitals’'^ participated in T2. These hospitals exercised the Illinois 
Department of Public Health (IDPH) Emergency Medical Disa.ster plan by responding to both 
simulated paper and actual patients that arrived at their emergency rooms or were reported to 
infectious disease personnel. After seeing the patients, the hospitals reported syndromic and 
other information to the IDPH command center, and the Illinois Operations Headquarters and 
Notifications Office (lOHNO), located during the exercise in Springfield, Illinois. lOHNO in 
turn worked with the IDPH and the Illinois State Emergency Operations Center (EOC) (also 
located in Springfield) to develop an overall picture of the medical situation. 

The IDPH disaster plan set up a hierarchal reporting structure for hospitals in the affected 
counties. Hospitals do not report directly to lOHNO during a disaster. Instead, hospitals within 



City of Chicago. DuPage County. Kane Couniy. Lake County, and Cook County. 
^ The evaJuation team has data from 60 of the 64 hospitals. 


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a designated region report to a “POD'^^” hospital. The POD hospital consolidates information 
from the regional hospitals and then forwards it to lOHNO. Figure 16 illustrates this reporting 
process. 



The medical disaster plan was first activated at 0830 Central Daylight Time (CDT)^’ on May 13, 
2003, in response to reported cases of Pneumonic Plague in DuPage County. The trigger was 
the result of an alarni on the DuPage County Pro-Net syndromic surveillance system. This 
system collected syndromic information from hospitals in DuPage County using a Web-based 
interface. The data collected are evaluated by software to determine if there are any unusual 
clusters or trends occurring. If an unusual spike in cases is detected the system alerts the local 
public health responders via a pager system. The initial alert on Pro-Net occurred at 1729 on 
May 12, 2003, due to an increase in respiratory patients at Edward Hospital, the first hospital to 
receive the simulated plague patients. In addition, the IDPH had sent a fax at 1545 to all 
hospitals on the subject of the TOPOFF Pulmonary Syndrome (TOPS). The fax was actually 
marked 2200 but was sent at the earlier time due to a controller miscue. 

The detection of an unusual number of respiratory cases in DuPage County triggered Phase I of 
the Public Health Emergency Plan. Upon declaring a Phase 1 Emergency the POD hospitals are 
to contact hospitals within their regions and request information for the Phase I Disaster POD 


“POD” is not an acronym in this usage. 

’’ All times referenced are CDT unles.s otherwise noted. 


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Worksheet. Table 6 lists the data elements collected on this worksheet. After collecting this 
information, the POD hospital is to transmit it to the lOHNO via telephone and fax. 

Table 6. Data Elements from Phase / }\orksheet 


Emereencv Department 

Trauma Center 

Adult Beds 

Pediatric Beds 

Total Other Beds 

Total Units Blood 

Ventilators Adult 

Ventilators Pediatric 

Ventilators Both 

Field Bags 

Decontamination 

Walking/hour 

Decontamination litter/hour 


The Emergency Medical Disaster plan data flow through the hospital emergency departments 
(EDs) then to lOHNO. During the FSE, patient data also reached IDPH through the infectious 
disease reporting system. By law hospitals have to report certain communicable diseases to their 
local health departments. This is usually done by the hospital’s Infectious Disease Control Nurse 
who is to report incidents of diseases directly to the local (city/county) health departments. In 
turn the local health departments report to the IDPH Infectious Disease Control. During the 
FSE. the Infectious Disease Control personnel co-located with lONHO in order to facilitate 
coordination. 

Activation of Phase 11 of the Emergency Medical Disaster plan occurred at 1235 on May 13, 
2003. Phase II activation was based on diagnosis of Pneumonic Plague in the suspicious 
respiratory cases. The Illinois Governor declared a statewide emergency at 1230 on May 13, 
2003. In addition to the IDPH and state declarations, numerous city and county emergency 
declarations occurred during this time period. 

Phase II activation requires additional, specific, information be reported by hospitals within the 
POD regions. Upon notification participaring hospitals report information on the number of 
patients currently in the hospital, the type of conditions these patients have been admitted for, 
and the number of available beds of different types. The data are documented in 
Table 7. 

Table 7. Phase II Resource Availability Worksheet. Hospitals Report the Number of In-patient 
Beds Currently Available for the Following Types of Hospital Care Beds 


Medicine 

Psych 

Surgery 

Orthopedics 

Bums 

Spinal Cord 

OB/GYN 

Pediatrics 

Negative Air Pressure 

Total 


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These bed totals are reported to the POD hospitals by telephone and fax, collected, and in turn 
reported by the POD hospitals to the lOHNO. 

3. Reconstruction/Analysis^* 
a. Communications and information flow 

Throughout the exercise hospitals communicated with each other and the public health system 
to; 

• Determine the status of beds, rooms, and supplies; 

• Recall additional personnel as needed; 

• Clarify the specifics of the exercise agent, including appropriate protectioir-ttti^ treatment 
protocols; and 

• Request assistance in the handling of the dead. 

A variety of communication methods were employed during the exercise including phones, fax, 
in-hospital public address systems, pagers, radios, human runners, and amateur radio operators 
(HAM). The.se communications are summarized in Figure . 17. The vast majority of all 
communications (eighty-six percent) were by either phone or fax» Thftie transmissions included 
both those within each hospital and conversaliooWfaxes to other hospitals and agencies within 
the emergency response community. 


Hospital Communications 



6 % 


5% 


2% 


1% 


Figure if'. Hospital Communications (all transmissions, all targets) 


Problems were noted with most of the.se communications routes. Telephone calls were 
hampered by problems with incorrect phone numbers, changes in contact phone numbers (at both 


This topic does not lend itself to a chronological reconstruction of evenLs. The reconstruction is effectively an 
account and analysis of varioas dimensions of hospital response to the bioterrorism attack. For this reason, the 
Reconstruction and Analysis sections are combined. 



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the Illinois and Chicago Departments of Public Health) necessitated by extremely high in-bound 
call volume, and outbound call volume that caused difficulties in obtaining outside lines. 

These problems caused delays in reporting resource information and also made it difficult for 
hospitals to recall staff through the use of phone trees. Call volume was the greatest problem; 
even exercise traffic exceeded some call switching capacities. For example, exercise traffic 
overwhelmed the phone system in south Kane County on May 14. 2003, necessitating the use of 
three HAM radio operators in order to maintain communications connectivity. 

Faxes suffered from their own transmission and receipt problems due to call volumes. “Blast fax 
transmissions” from lOHNO, used to provide a wide variety of information and exercise updates, 
took up to two hours to complete. Some fax transmissions early in the exercise weren’t reviewed 
immediately because the receiving fax was in an office locked for the evening or not easily read 
by ED staff. Because of this, some hospitals designated individuals to staff the fax machine. 

Radios were used primarily to communicate within a single hospital or between hospitals and 
incoming Emergency Medical Service (EMS) units. In addition, radios were used for backup 
communications at both St. Therese and LaGrange Hospitals during phone outages in the ED. 

A great deal of effort was made during the exercise to obtain and update the listing of available 
resources reported by phone or fax. As shown in Figure 18. at least twenty percent of hospital 
exercise communications consisted of this type of reporting. It is important to realize that not 
only do these reports take time to send, but it also requires a great amount of time to obtain the 
information contained in these reports. The information consists primarily of bed counts, 
ventilator counts, and the number of rooms available at each hospital. Those counts were 
obtained either through additional phone calls to floors throughout the hospital or via walking the 
hospital floors to obtain the counts. This type of inventory effort was repeated throughout the 
exercise - usually at three- to four-hour intervals — at each of the 64 participating hospitals. 

The remaining hospital communications consisted of notifications, mostly those associated with 
deaths. In addition, normal ED operations required a wide variety of contacts inside and outside 
of the hospital. A partial list of the individuals or departments called from the EDs includes; the 
hospital Chief Executive Officer and Vice President for Medical Affairs, the Command Center, 
floor nurses, the Intensive Care Unit, Infection Control, the Pharmacy and Blood Bank, 
housekeeping, and transportation. 

Communications were also required among numerous agencies and organizations outside of the 
hospital, including, among others, the coroner, the American Red Cross, the Poison Center, the 
IDPH, and the county Department of Public Health (DPH), and the county’s Office of 
Emergency Management (OEM). 


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Bed, Resource Reports 



By phone: 10.5% 


By FAX: 9.5% 



Other comms: 80% 


Figure 18: Hospital Resource Reporting 
b. Beds 

Twenty percent of all communications involved asking for and sending resource information. 
Counts of available patient beds were needed to detmnine if patient loads required additional 
resources, up to and including field hospital deployment. Therefore, as part of normal 
emergencies, individual hospitals provided bed counts to their coordinating POD ho.spitals, 
where the information was consolidated and sent to lOHNO. 

During the exercise, a number of observations indicated that this process was difficult, at best. A 
data collector wrote, “An observation is this hospital is dealing with a large amount of 
paperwork — dealing with bed availability of POD hospital” 

Some confusion existed as to the “why” of bed counts and the “which” of bed counts. For 
example, a data collector observed; “Discussion with physician about full disaster mode and 
purpose of meetings to know what beds available and sending patients as fast as possible to keep 
ER lemergency room] free.” 

The nofsing supervisor talked to hospital staff about requesting a federal count, but there was 
confusion ns to exactly which beds were to be included in the count. 

At least six hospitals did experience maximum capacity situations, when either the entire hospital 
was full, or all the critical care beds or intensive care beds were in use. One hospital reached 
capacity at noon on May 13, 2003, two additional hospitals reached Intensive Care Unit (ICU) 
capacity shortly thereal'ter on the same day, and a fourth later that same evening. The next day’s 
play filled the fifth hospital’s ICU beds by noon. By early afternoon on Wednesday May 14, 
2003, the sixth hospital’s ED doctor indicated. “We’re coming to the breaking point.” At the 
same moment, the bed placement nurse commented to Hospital Admitting, “We are running out 



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of critical care beds.” Since Pneumonic Plague can cause severe respiratory disease, critical care 
and ICU beds will be at a premium if such a bioterrorism attack were ever to occur. 

Types of beds needed to treat patients (as played during exercise) 

During the exercise, a variety of bed types were specifically requested as part of normal medical 
treatment of the exercise patient population. These types included intensive care beds (ICU, 
Thoracic ICU, Mobile ICU. Pediatric ICU, and Surgical ICU beds), critical care beds in the 
Critical Care Unit (CCU), medical-surgical beds, other general medical floor beds, and pediatric 
beds. In addition to beds, monitoring capabilities were required for a portion of the patient 
population, and were requested as deemed medically necessary. The need for respiratory 
isolation and negative pressure rooms during the outbreak of a contagious respiratory disease 
was noted; the details of those specific requirements are discussed in the next section. 

Bed use strategies and coordination 

The FSE hospital play demonstrated the flexibility and creativity of hospital staff — as they 
juggled bed requirements for a significant influx of Pneumonic Plague patients. Different 
strategies were used to maximize the number of beds available to serve patient needs. For 
example, a wide variety of “other” beds were located throughout the hospitals and u.sed for 
exercise patients. Throughout hospitals extra beds were found in Occupational Health, 
Ambulatory Care, Psychology, and Labor and Delivery. In at least five hospitals, additional beds 
were placed in the Endoscopy laboratory. The Physicians Treatment Center associated with 
another hospital was used for additional beds. One hospital also considered the suggestion that 
an entire wing be emptied, a suggestion that was not nolionally implemented. 

Significant numbers of personnel were directly involved in bed coordination efforts during the 
exercise. These included, but were not limited to, the following staff positions; 

• Nursing Supervisor; 

• Bed Coordinator; 

• Bed Control; 

• ED Charge Nurse 

• Nurse Manager; 

• Case Manager;^ 

• Doctors; 

• Admitting: 

• Maintenance; 

• Registration; and 

• Administration. 

The coordination of this information was done through phone calls, fax, and hard copy tracking 
using dry erase boards throughout the exercise. 



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c. Staff 


In addition to other resources, considerable staffing is required to respond to a major outbreak. 
The staff is required to treat and support the patient load, as well as support the administrative 
and command and control workload that will be placed on the hospital to support various 
coordination requirements. The FSE response proved to be no different. Staff phone trees were 
activated on both days of hospital play to recall doctors, nurses, and other staff to assist in the 
response efforts. 

Staff recalls included not just doctors and nursing staff, but also receptionists and administrative 
personnel to handle paperwork requirements, housekeeping staff, technicians, computer 
personnel, and security, if lockdown procedures proved necessary. These individuals formed the 
basis for an emergency labor pool. 

During the FSE, there were also other functions to which hospitals did not always assign a 
particular staff member. These jobs included persons to staff the radio full-time, staff the fax 
full-time, staff phone hotline(s) for the public, and assist in making phone calls. 

Other infectious disease needs also require coordination to permit emergency personnel to work 
during an outbreak or a bioterrorism attack. These include phildcare for the staff during the 
outbreak; one hospital’s childcare facility notified the ED’^that”’'they would stay late to 


accommodate staff needs. In addition, extended hours 
cots/beds are necessary during the outbreak. 


d. Isolation rooms 


xtended hours also mean 

<?- 

piratoryWyndrome (SARS 


that additional food and 


Because of the recent Severe Acute Respiratory^yndrome (SARS) outbreak, the need for 
isolation and reverse pressure roon ^faa^ been higfflighted, especially in the context of an 
unknown respiratory disease that may in its infectivity. These two types of 

requirements also played a role in the hospitals’ responses to the T2 exercise epidemic. 

Isolation Strategies 

Three types of isolation levels were used in the participating hospitals. Initial patient 
presentations indicated the |Mt»bable need for respiratory isolation and/or maintenance of the 
patient in a negative air pressure room. In addition, IDPH sent out an isolation directive on the 
evening of May 12, 2003. Later during the exercise, when the agent was identified as 
Pneumonic Plague, these isolation requirements were revised to the appropriate droplet 
protection level. 

Because isolation rooms were in short supply, and at least two hospitals used up their supply of 
isolation rooms during the exercise, a number of alternatives were employed to provide patient 
isolation. Hospitals used lobbies, extra conference rooms, and Clinical Decision Units (closed 
units) among other spaces. 

Negative pressure rooms are also normally in short supply. At least three hospitals used up their 
supply of negative pressure rooms at various points during the exercise. Again, hospital staff 
developed a number of alternatives to deal with the short supply including the use of spaces in 
radiology, same day surgery, the Endoscopy lab, and an off-site tent with negative pressure. 

In addition, at least six hospitals contacted maintenance/facilities personnel to request additional 
reverse pressure rooms. Lastly, because both isolation and negative pressure rooms were in short 


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supply, at least eight hospitals placed their Pneumonic Plague patients in either isolation rooms 
or reverse pressure rooms. 

Changeover to droplet isolation 

As soon as the causative agent in a respiratory epidemic is determined, it should be possible to 
downgrade the isolation levels to droplet/contact precautions. The downgrading to the lower 
precaution level, however, did prove to be somewhat confusing and required confirmation. As 
seen in the following group of observations from May 13, 2003, one hospital look almost ten 
hours to be convinced; even after a number of checks, the Vice President for Medical Affairs had 
to convince the hospital ED staff that contact and droplet isolation was, in fact, sufficient. 

• 1047: Nursing supervisor informed “we don’t need reverse flow. We’re assigning 
by unit for droplet and contact isolation,” as per the Vice President for Medical 
Affairs; 

• 1138: Infection Control manager here— confusion about whether patients need to 
be in negative flow versus contact and droplet isolaticm fttMn ED staff/medical 
doctor (MD); Infection Control Manager leaves to go to Control Center to verify; 

• 1 140: Call from Control Center — “Dr says we don’t need reverse flow. We 

can do contact and droplet isolation” stated an ER Charge RN to staff/MDs in ED; 
and 

• 2040: the Vice President for Medical Affairs clarified with ED staff/MD that 
reverse airflow isn’t needed — contact and droplet isolation is sufficient. 

e. Resources: masks, and Personal Protective Equipment 

The recent outbreak of SARS has also generated a great deal more emphasis on the importance 
of respiratory protection for patients and about higher levels of Personal Protective Equipment 
(PPE) for hospital personnel who come in contact with them. For an outbreak of Pneumonic 
Plague, masks are likely to represent an important means for infection control. During the FSE, 
the following hospital personnel were identified as potentially vulnerable to infection and thus 
required some form of droplet protection: doctors, nurses, triage and front line ED staff. X-ray 
technicians, security, registrar, and volunteers. 

Figure 19 provides a breakdown of the various types of PPE worn by hospital personnel as noted 
during the exercise. Each category indicates, at a minimum, that particular pieces of equipment 
were being worn. The category PPE does not specify any one piece of equipment; the 
observations in this category likely range from masks up to mask, gown, goggles, and gloves 
worn by the staff member(s) being observed. 

Figure 20 provides a breakdown of the various types of personal protective equipment worn by 
the exercise patients as noted during the exercise. The same categories were used for this plot as 
for Figure 19. 

Both graphs note small, but important percentages of persons who were not wearing any masks. 
For the hospital personnel it is likely that this six percent is somewhat of an overestimate, 
because some notations in the data indicate staff and some notations call out a single individual. 
The patient number is a more reliable figure, since patients were not grouped using a similar 


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staff-like term. Regardless, it is important that the numbers in this category, whether hospital 
staff or patients, are as few as possible. 

N-95 masks 

During the exercise, both N-95 masks and surgical masks were used for PPE. Some EDs started 
the exercise using surgical masks then switched over to N-95 masks as the outbreak progressed. 
Others used the N-95 masks, but required some amount of additional instructions to use. One 
hospital was observed as having had all their nurses fitted for N-95s. The hospital also had 
adequate supplies of these masks throughout the exercise. Another hospital commented that not 
enough sizes were available. Other hospitals ran out and had .some difficulty re-stocking. In 
DuPage County, it ultimately fell to DuPage County’s EOC to coordinate a re-.supply of masks to 
their county hospitals. 

+Gown/Gloves: 6% 

+Gown: 5% 

■fGloves: 5% 
^y^+Goggles: 5% 


No Mask: 6% 



Wearifig Protective bear (Hospital Staff) 

Figure 19. Wearing ofProt^tive Gear by Hospital Staff (Clean Up?) 


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PPE: 3% 


+Gown: 2% 


No Mask: 8% 


Wearing Protective Gear (Patients) 


Figure 20. Wearing of Protective Gear (Exercise Patients) 
f. Resources: handling of the dead 

The FSE play included handling of the deceased and mortuary affairs. During the full five days 
of the exercise, 1,521 persons died as the result of the outbreak. Fewer exercise victims died 
during the three days of hospital play, but these casualties .still stressed the morgue capacity for a 
number of ptuticipating hospitals. In fact, on the evening of May 13, 2003, three hospitals had 
reached their maximum morgue capacity. 

Alternative morgues 


/ 


A number of alternative morgue options were developed over the course of the exercise. These 
included other hospital sites (hospital garage, hospital bam, and a local ice rink) in addition to at 
least two different sizes of refrigerated trucks (truck capacity; 40 bodies; truck capacity; 108 
bodies, based on exercise data). 

These alternative morgues also required a morgue leader to set up and coordinate body storage 
and subsequent transport, as well as supplies such as body bags and duct tape. As part of this 
process, while such alternative morgues were being selected and established, temporary body 
storage was also provided for the hospital in the preliminary storage areas, which included: 

• Increased stacking levels in the already full hospital morgue; 

• Procedure Room: 

• Urgent Care Area; 

• ED; and 

• Hazardous Materials Room 

Some of these preliminary storage areas might have been refrigerated (one doctor ordered 
portable cooling units for this purpose) but the majority likely was not. 



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In DuPage County actual contact was made with the Union Pacific Railroad requesting 
refrigerated box cars to be used as temporary morgue facilities. Located immediately north of 
the county campus, the Union Pacific Railroad simulated the closing of a mainline track, and 
provided three refrigerated cars to expand the county’s morgue capabilities. 


Notifications/reporting of the dead 



Other: 4% 


Antibiotics: 40 


Antibiotics Prescribed 


Deaths were counted and reported to the POD hospitals and then to lOHNO. This significantly 
increased the reporting requirements placed upon the hospitals. Along with a number of internal 
notifications, hospitals also sent this information to the County EOC. the County OEM, the 
Coroner, the Medical Examiner, the American Red Cross, the Funeral Director Association, and 
Funeral Homes (for the transport of non-infectious remains). 


g. Antibiotics 

Antibiotics were used as soon as the initial exercise patients arrived at hospitals. Figure 21 
provides the percentage breakdown of antibiotics used to treat the p^nis throughout the three 
days of hospital play. The Antibiotic category includes all notations of abx in the data, where the 
data collector did not identify the specific prescription. The category Other consists of 
prescriptions of Chloramphenicol, Zithromax, and Amoxicillin, which were grouped for clarity. 
In addition to these pre.scriptions, eight percent of patients received two antibiotic prescriptions, 
primarily because medical personnel were suspicious of terrorism early in the exercise. Later in 
the exercise, two prescriptions were given because the centers for Disease Control and 
Prevention expressed concern that this strain of Pneumonic Plague may be resistant to traditional 
antibiotics. 


Ciprofloxacin: 17% 


Levofloxacin: 4% 
Doxycyciine: 9% 


Rifampin: 6% 


Figure 21. Antibiotics Prescribed during the Three Days of Hospital Play 


In addition to both intravenous (IV) and oral antibiotics required for patients, hospitals provided 
either Ciprofloxacin or Doxycyciine to their personnel once Pneumonic Plague was suspected 
and positively identified by IDPH. One hospital used Employee Health to manage the 



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distribution effort. Another hospital tasked Hospital Infection Control to determine the amounts 
of antibiotic supplies needed. A third tasked their Isolation Nurses with notifying the pool of 
personnel exposed prior to the discovery of the outbreak. 

Per ED requests, hospital pharmacies determined the on-hand supplies of antibiotics for both 
patients and staff. For patients, stocks of the IV/oral supplies of Gentamicin, Streptomycin, 
Vancomycin, Ciprofloxacin. Levofloxacin, Chloramphenical and Doxycycline were checked. 
Pharmacies were also tasked with additional orders of Ciprofloxacin and Doxycycline. In 
addition, at least one pharmacy was tasked to call the EOC to request the activation of the 
county’s stockpile of antibiotics. 

h. Additional space requirements 

In addition to the previously mentioned requirement for additional beds, isolation rooms, reverse 
pressure rooms, and increased morgue capacity, and other space was voiced during T2. These 
needs also included additional space to triage patients, space to en^le the ER to be segregated 
by plague patients versus non-plague patients, and a separate site to handle the worried-well. 

Hospitals utilized various spaces to meet the additional triage requirements, including break 
rooms, hallways, the entrance outside the ED, pediatrics ER. minor care, and the catheterization 
lab. For the worried-well, at least one option considered was the helicopter hanger. The Family 
Medical Center department of at least one hospital was used for segregating the ER. 

i. Ventilators 

Responding to a large outbreak of a severe respiratory di.sease will require the use of respiratory 
support for the most critically ill patients. As was true with the other resources examined in this 
reconstruction, ventilator supplies were also counted and their numbers provided to POD 
hospitals and then lOHNO. On the morning of May 14. 2003, lOHNO requested additional 
ventilators from the Vendor Managed Inventory of the Strategic National Stockpile. This request 
was based upon patient number projections, not upon the number of ventilators currently in use 
at the time. During actual hospital play, in fact, the supply of ventilators appeared to remain 
adequate. Only one of the seven ho^itals. for which ventilator data were available, indicated a 
need for more ventilators early on the evening of May 13, 2003. 

4. Artificialities 

Several artificialities or artifacts of exercise play affected the analysis of hospital play: 

• Multiple reporting chains, the plethora of patient .statistics available (reports from the 
media, control injects, the hospitals, etc.), and the number people in the reporting chain 
all complicated patient reporting. In many cases, individuals were able to obtain patient 
statistics from sources not anticipated or known by exercise control. During an actual 
event, patient counts would be generated through the reporting, not from the interaction 
of the reporting chain with exercise control; 

• In a real event the reporting system would be more complex, with requirements to report 
on the evolution of the patient population as well as the general statistics (affected, dead, 
etc.); 


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• The Metropolitan Chicago Health Care Council (MCHC) injected additional, unscripted, 
patients into the exercise during the early phases of the exercise. These patients were 
intended to assist MCHC hospitals maintain their accreditation. However, these patients 
were inadvertently configured to resemble T2 FSE scripted patients, resulting in a 
distortion in the numbers of patients reported; and 

• During the FSE, some media play was scripted. This meant that in some instances the 
reported patient numbers were based upon exercise injects, not the actual numbers of 
patients reported to decision-makers. One example of this type of reporting occurred 
with the Office of the Governor of Illinois. Ground truth patient counts had been given to 
the Governor prior to the start of the exercise. Using these numbers the Governor taped 
several interviews or reports incorporating those numbers. However, when they were 
broadcast, the ground truth numbers were significantly different from the patient numbers 
held by the State and local governments and public health authorities. 

5. Conclusions 

During a crisis like the one simulated in the Illinois venue, communicating data and information 
is critical to developing an accurate and comprehensive picture of what is happening. 
Communications require both a robust 
transmission system and sufficiently trained 
personnel to ensure that the communications 
occur and that the results are verified, then 
passed to the appropriate locations within the 
receiving organization. T2 illustrated the 
diversity and complexity of managing 
response resources in the public health and 
medical environment. With 64 ho.spitals. five 
POD hospitals, and three separate but 
interrelated statewide organizations (IDPH, 
lOHNO. IL State EOC) all collecting data and 
attempting to coordinate actions, information 
and data flow requirements became intense. 

Hospitals and public health departments 
generally do not have the experience or the 
extra staff trained to handle large volumes of 
emergency communications. While 

personnel may be trained to operate particular 
fax or voice circuits, the existing infrastructure may not be adequate to sustain robust 
communications during a crisis of the type simulated during T2. Thus, as was the case in this 
exercise, problems develop when the system is activated. 

During the FSE, the lack of a robust emergency communications infrastructure was manifest by 
a reliance on telephones and faxes for data transmission versus electronic transmission of data. It 
was also manifest in the loss of fax machines due to mechanical breakdown, inadequate staff to 
monitor them, or loss due to after-hour rooms that were locked. Likewise the lack of verified 
phone numbers for communications caused delays while emergency personnel looked for the 
correct numbers to report emergency data. 


Summary of Conclusions — 
Hospital Pi.ay in thk Illinois Venue: 


The T2 FSE exercised 64 hospitals in the Illinois venue 
making it one of the largest mass casually exercise 
ever undertaken. 

Hospitals still rely on telephones and faxes for data 
transmission vice electronic transmission. This 
manifested itself as a significant challenge during the 
FSE due to mechanical problems, inadequate 
staffing, and loss of data. 

Hospitals should consider implementing a system in 
which data is entered digitally then transmitted 
electronically. This would eliminate many of the 
manual steps observed during the FSE and has the 
potential to minimize errors. 

Because of the dual communications chains that exist, 
there is a need for organizations to coordinate the 
receipt and processing of information. 


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At the most basic level, it is possible to establish some principles for developing an effective 
emergency data communications system, which is essentially what was occurring as the hospitals 
reported syndromic, patient, and infrastructure information: 

• Communications need to be robust and verifiable. It is critical that communications are 
being directed to the correct [personnel or organizations (i.e., e-mail or telephone numbers 
must be correct) and that the receiving organizations received the right information. A 
record of the transmission is also required; 

• Data should ideally be communicated over data lines, not voice or fax. Voice systems 
are good for person-to-person coordination (not necessarily organization to organization 
coordination), but neither voice nor fax are optimal ways to communicate numerical data. 
Using data communication techniques (e.g., e-mail, Internet transmission) Ieave.s the data 
in machine-readable formats upon receipt; 

• After they are generated, as few human hands as possible should touch data to minimize 
errors. For example, if information is copied down manually on a form, then the form is 
faxed (possibly degrading its readability) to a collection point, where it is then manually 
tabulated on another form, as is consistent with the IDPH emergency plan, and then 
entered into an information system for transmission, the potential for errors increases 
significantly; and 

• Whether using data lines, voice, or fax, care must be made to ensure the security of the 
information being transmitted. 

One way to overcome difficulties in the collection and reporting of data is to have data entered 
digitally at the point of origin, then transmitted electronically in digital form to all those who 
require the data. This would eliminate many of the manual .steps currently involved in data 
generation at the hospital level, and provide for a more robust and verifiable set of data once it 
was received by one of the POD hospitals and lOHNO. 

A larger issue, that was mme difficult to document, was the movement of information within 
organizations once the infwmatiwi was obtained. The dual communications chain observed in 
the FSE, with the IDPH Infectious Disease Control receiving reports from local public health and 
lOHNO receiving reports from emergency departments at hospitals, is an example of the need 
for coordination within organizations for the receipt and processing of information. 

The FSE resource requirements illustrated both the diversity of resource types required to 
respond to thousands of sick, dying, and dead, as well as the diversity of organizations looking 
for and providing resources. With 64 hospitals all looking for essentially the same set of 
resources, a wide range of potential solutions were developed to address the problem. 

However, without adequate resource tracking it will be impossible to effectively allocate, 
expand, or acquire resources that address .specific needs. Instead a general diffuse and 
untargeted effort to acquire re.sources will evolve as a result. 


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G. Decision-making under Conditions of Uncertainty: The Plague Outbreak in the Illinois 
Venue 


1. Introduction 

During a disease outbreak, whether naturally occurring or initiated through an act of terrorism, 
decision-makers must rely upon scientists, medical doctors, and the public health system for the 
information needed to make effective response decisions. Examples of such information include 
the progress of the disease, the behavior of the disease in various populations, and assessments of 
how the disease might be spreading. Often the early science on these questions is ambiguous or, 
in the case of historical diseases, open to various interpretations.^ 

Decision-makers must work to formulate the right questions, and then interpret the answers 
within the context of the logistical, political, social, public health, and economic aspects of the 
response. This is difficult under the best of conditions, and made even more difficult during a 
terrorism response operation due to the enormous media and time pressures that decision-makers 
will be operating under. 

The Top Officials (TOPOFF) 2 (T2) Full-Scale Exercise (FSE) provided a unique environment 
that can be used to examine decision-making under conditions of information uncertainty. 
During the FSE, public health officials initially knew neither the extent nor duration of the 
terrorist-induced epidemic of Pneumonic Plague. These facts permit an examination of several 
questions related to decision-making under uncertainty, such as: 

• How was the extent of the epidemic estimiUed; 

• What were the estimates; 

• What techniques were used to jxovide these estimates: and 

• Did these estimates subsequently affect decisions (requests for resources, other teams, 
and capabilities)? • 

This Special Topic examines these questions in the context of events that occurred Illinois venue 
during the FSE. During the early phases of the exercise, participants were only seeing the tip of 
the iceberg in terms of the eventual numbers of patients that would develop. How they oriented 
themselves to the evolution of the disease and what impact that had on planning were aspects of 
the exercise in which science and policy-making interacted. 

2. Background Pneumonic Plague 

a. Defining the information iceberg problem 

During the FSE, a simulated outbreak of Pneumonic Plague occurred in the Chicago 
metropolitan area. To illustrate the challenge of estimating the long-term consequences of the 
outbreak, the plot graph in Figure 22 shows the T2 scenario’s patient population broken down 
into five potential pools: Not symptomatic, mildly ill, severely ill but not in a hospital, severely 
ill and in a hospital, and dead. 


Science: P. Anand; “Decision-making when Science is ambiguous" 8 March 2002, Volume 295, page 1839. 


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The plot shows the number of cases of Pneumonic Plague increasing along the negative y-axis, 
with time increasing along the positive x-axis. The figure is constructed this way to simulate a 
metaphorical iceberg, with x = 0 symbolizing the waterline. As the days of play continue from 
May 11 through May 14, 2003, only small fluctuations are seen in the number of persons 
diagnosed with plague. However, after May 14, 2003, the number of cases increases 
dramatically from less than 1 ,000 to more than 20,000. 


This is termed the information iceberg, as the early presentation of the disease does not really 
foreshadow the potential size of the epidemic. The patients who present symptoms , early in the 
epidemic are seen as the tip of the iceberg with their numbers appearing above the waterline, as 
they bring themselves into the hospitals for a-ssessment and subsequent treatment The remaning 
pool of patients remains under the waterline of the iceberg, where the graph eiiSsl^ the lastly 
of the exercise. 

Understanding and successfully predicting the effect of the iceberg is criTic^o'decisiot^'makers. 
During the early stages of an outbreak, decision-makers are likely to see reports about only the 
early presenters, not the full number of exposed persons. It is'^absolittely critical to determine 
rapidly the scale of the outbreak. This is especially true in caes of potenti^bioterrorism where 
traditional epidemiological curves could be multiplied by multiple, continuing, or widespread 
initial exposures. 

Public health officials, and other decision-makeis^mav determin^the scope of the problem by 
employing epidemiological models based u^ datareported by physicians, hospitals, and the 
public health infrastructure, as well as developingCa clear understanding of the nature and 
transmission mechanisms of the disease; but theyjmust at'so'factor in additional assumptions in 
the case of bioterrorism. 




V 


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a. STARTEX 


ILENDEX 


4- S 


'Visible bp" 



□ □■Id I 

□ SflVM'HoApitilTad I 

• No Smptoms 

□ Hos»t«llBd 

• MU 


Figure 22. The Iceberg of Patient Population 




T2 


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b. Decisions using estimates and models 

How do epidemiologists estimate the size and behavior of the disease 

A common approach for approximating these elements is to use models to estimate the progress 
of the disease. However, incorrect, incomplete, or inaccurate data or assumptions and 
information input to a good model can result in sub-optimal results for decision-makers. It is 
important for decision-makers to understand that even with good data, models are only an 
approximation of reality. In the case of a disease outbreak, data on the disease does not appear 
instantaneously at exactly the right time for decision-making. Instead it may be delayed and may 
contain inaccuracies. Mechanisms may not be in place to collect the right data in a timely 
fashion. Finally, the models themselves are approximations of the actual process by which 
diseases spread. It is also important to note that models are even less reliable when dealing with 
disea.ses like plague, particularly Pneumonic Plague for which there is a paucity of data. 
Additional complications occur with diseases that are deliberately introduced and optimized by 
terrorists to achieve high mortality and morbidity. 

The estimates that models provide may well change over time as more data become available. A 
number of T2 After Action Conference (AAC) participants indicated “neither decision-makers 
nor the American public understands models and, in particular, won’t accept the fact that the 
answers keep changing.” Continuous changes in estimates can be disconcerting to decision- 
makers, and the general public. 

c. T2 Chicago venue scenario and patient breakdown 

The FSE Illinois patient population consisted of an initial group of 3,100 individuals exposed to 
Pneumonic Plague. This group would ultimately infect an additional secondary population of 
18,434 persons. When exercise brevity (five days) is compared with the designed epidemic 
length (eleven days, from original exposure to D+9), the impacts of the 21,534 affected 
individuals were not fully explored. 

The affected population design was initially divided into five separate categories: Not 
symptomatic, mildly ill, severely ill but not in a hospital, severely ill and in a hospital, and dead. 
Subsequent changes to this original design were accomplished in consultation with Illinois 
Department of Public Health (IDPH). These changes were designed to provide a reasonable 
repre.sentation of the respon.ses individuals would have to becoming ill with Pneumonic Plague. 
The additional breakdown laid out twelve separate tracks that determined when the patients 
would arrive at hospitals, or if individual patients would avoid hospitals and seek medical care 
elsewhere or not at all. The breakout of these tracks is provided in Figure 23, which is color- 
coded to indicate those patients who would be captured as part of normal hospital reporting 
protocols. The red script indicates those infected individuals who would remain largely 
uncounted by the hospital system playing in the exercise but who would eventually require care 
nonetheless. 


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IL Patient Breakdown 


Category 1 : PT to Doctor 


Track 1: Assess, w/o prescription 



Track 2: Assess, w/ prescription 


Track 3: Assess, to hospital 


Category 2: PT to Urgent Care Track 4: Assess, w/o prescription 



Track 5: Assess, w/ prescription 


Track 6: Assess, to hospital 


Category 3: PT to Hospital 


Track 7: Assess, w/o prescription 



Track 8: Assess, w/ prescription 


Track 9: Assess, admission 


Cate gory 4: PT to Distribution Ctr ^T rack 10: Prescription 


Track 11: Assess, to hospital 


Category 5: PT w/o Medical care Track 12; Dies (in community) 


Black = Counted by system Red = Not counted by system 
Figure 23. Illinois Patient Breakdown ^ ^ 

Figure 24 summari7-es the number of victims who were infected (both the primary and secondary 
exposures) and those who would be so severely ill as to require hospital treatment for the days of 
the exercise. 


Total Victim s 



Figure 24. Total Exposed Population Compared With the Hospital-Counted Victims (All 
times Central Daylight Time (CDT)) 


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3. Reconstruction (all times CDT) 

a. How accurate was the data reported by hospitals 

Patient counts reported by hospitals and physicians were lost during the exercise for a number of 
reasons. Patients may not have been counted because they did not report to hospitals or because 
the counts were corrupted somewhere along the way. This section discusses how information 
was lost to epidemiological modelers, public health officials, and other decision-makers during 
the exercise. 

The data used to estimate the epidemic spread during the FSE suffered from three problems: 

• Some data were simply not observed at the point of origin; 

• If the data were observed, they may not have been reported accurately. For example, an 
accurate count of patients was incorrectly entered into a data reporting system; and 

• The data may have been incorrectly defined. Even with accurate numbers, not all of the 
patients were placed in the correct category. 

Figure 24 illustrates the problem of unavailable data: Some patients were not entered into any 
data system. These patients could not be added to any hospital patient counts because they either 
never went to a hospital or they were released upon assessment in the Emergency Department 
(ED) and not counted. 

Table 8 summarizes the percent of victims who were eventually seen at hospitals but who 
remained out in the community until they received treatment at hospitals or from their doctors, or 
died from the disease. At the end of the exercise, approximately seventy-five percent of the 
exposed population remained unseen because they had not yet become more than mildly 
symptomatic. 

Table 8. Percent of Infected Population Seen in Hospitals by Exercise Date/Time 


Time 

Total seen 

Total Infected 

% 


13 May 0800 

283 

5656 

5 



6634 

6.9 

14 May 0800 

2566 


15.2 

14Mav 2000 

2977 

21534 

13.8 

15 May 0800 

3546 

21534 

16.5 


4084 

21534 

19.0 

16 May 0800 

5322 

21534 

24.7 


Inaccurately reported data can be detected by comparing patient numbers reported and logged at 
the Illinois Venue Control Cell (VCC) with the ground truth scenario patient population. The 
patient data for the 1700 - 2400 timeframe on May 12, 2003, is provided in Table 9. The 
numbers vary considerably from the ground truth, depending upon which source is consulted 


This is the time period during the exercise where the Metropolitan Chicago Health Care Council did not inject 
additional patients into the patient population. 


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(both hospital patient numbers and public health numbers were logged on VCC wall charts and 
the VCC controller log has also been reviewed). 

As can be seen in Table 9, none of the logs of patient counts maintained by the VCC agreed 
completely with the ground truth patient numbers from the scenario. This may be the result of 
the complex way in which patient data was exchanged. Communications took place over fax, 
landlines, and cell phones. This led to a number of ways to log the data as well as a variety of 
different people reporting the data. Variance in the reporting source and the method of reporting 
probably represents part of the reason why patient counts vary. 

It is also important to note that the 1700 - 2400 timeframe on May 12, 2003, represents data from 
the earliest part of the exercise. After this time, patient numbers climbed considerably. If 
reporting wasn't accurate early on, during a low volume of patients, it might be expected to lag 
behind actual counts under the more stressful conditions of higher patient volumes. 
Unfortunately, due to the problems encountered with patient numbers later in the exercise, it was 
not possible to determine whether the variance in patient counts actually increased as the 
exercise progressed. 

Table 9. Reported Patient Numbers Logged at VCC as Compared to Actual Scenario Numbers 
(May 12, 1700-2400) 


City/ 

County 


Hospital 

Patients 

(Ground 

Triith) 


Hospital 

Patients 

Lo<;<;ed: 

VCC 

Chart 


Hospital 

Patients 

LtMJGEDJ 

VCC 

Lot; 


Public 

Health 

(Ground 

Truth) 


Public 

Health 

L<k;(:ed: 

VCC 

Chart 


Hospital 

Deaths 

(Ground 

Truth) 


Deaths 

Logged: 

VCC 

Chart 


Chicago 


Cook 


22 


38 


11 




V 

V 


10 


29 


16 


43 


29 


12 


76 


26 


42 


Another reason why the counts in Table 9 do not match is that the definitions of what was being 
reported do not necessarily match. As noted earlier, the ground truth scenario divided the 
patients into pools of those who would visit the emergency department (ED), those would 
subsequently be admitted, those patients sent to the emergency room by their doctor or by 


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another medical facility, and the dead. These specific definitions, however, were not adhered to 
by reporting hospital personnel and resulted in patient reports that, while counted in the totals, 
would not have accurately reflected the scenario. 

b. Estimating the course and scale of the epidemic 

During the FSE, participants used a number of approaches to produce estimates of the 
Pneumonic Plague epidemic. The results of these efforts helped determine strategies for 
antibiotic distribution, the need for additional antibiotics from the Vendor Managed Inventory, 
and the need to identify additional sites for patient treatment and handling of the dead. It should 
be noted that in the case of a terrorism attack, the progress of the disease would likely exceed 
that which would be encountered in a natural outbreak, suggesting that decision-making would 
need to be guided by a broader understanding of the threat environment. 

The following sections describe several of the different approaches that were used to estimate the 
affected population during the FSE. These approaches are compared to the ground truth 
numbers for patient counts in the scenario, not for the purposes of critiquing them, but to indicate 
the ways organizations approached these types of problems. 

Example I (Patient estimate). Illinois Operational Headquarters and Notification Office 

Based upon the reported patient numbers at 1600 on May 13, 2003, (338 cases, 154 dead)'°', 
Illinois Operational Headquarters and Notification Office (lOHNO) personnel used a simple 
approach to estimate the numbers that might be presented to their hospitals over the next few 
days of the exercise. They chose a multiplicative facttw (initially 5-6). This factor was a means 
to estimate how many additional cases each initial case could produce. This resulted in an 
estimate of 2,000 cases with 1,000 dead for a total of roughly 3,000 affected persons. The 
multiplicative factor was almost immediately doubled, producing estimates of 4,000 cases with 
2,000 dead, for a total of 6,000 affected individuals. 

The factor was doubled because lOHNO felt that the patient numbers were being significantly 
underreported. It is interesting to note that this rough estimate was within fifteen percent of the 
final actual total patient population at 1200 on May 16, 2003, (5,349 cases, 1,521 dead, total of 
6,870), which overestimated the dead and underestimated the survivors. 

Because the State of Illinois has a total of 8,263 beds statewide, some of which would be not be 
used for plague patients, this lOHNO estimate suggested that hospital facilities would be 
severely strained by downstream patient numbers. More significantly, this estimate was used to 
request two Disaster Medical A,ssistance Teams and one Disaster Mortuary Operational 
Response Team. lOHNO’s approach depended heavily upon the expertise of those making the 
estimates. 


Note that this is out of the range of the May 12, 2003, data presented in Table 9. However, as was argued in the 
previous section, inaccurate early data counts are likely indicators of inaccurate counts throughout the exercise 
period. Thus, it is likely that these initial numbers, and all those quoted in these examples, differ from ground truth 
by an unknown but significant amount. 


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Example 2 (Patient estimate). Data obtained from the Chicago-area FEMA Regional 
Operations Center 

Data from the Chicago-area FEMA Regional Operations Center (ROC) indicated that an estimate 
of the epidemic was provided during a briefing on May 16. 2003. The graph shown in Figure 25 
is a copy of the graph used in the ROC. The numbers used were those reported by the IDPH. 



8000 

7000 

6000 

5000 

4000 

3000 

2000 

1000 

0 


^ 

«, Jo Jo Jo Jo Jo A 

^ 4 ^ 4 ^ 4 ^ 4 ^ 4 ^ 4 ^ 4 ^ 


Figure 25. Chicago-area FEMA ROC Patient and Dead EstimatesA significant problem is 
apparent from an examination of this graph. The data on the x-time axis are plotted at equal 
intervals. However, the actual time intervals on the plot are not equal even though they are 
portrayed that way, As a result, the straight line fit through the data is incorrect. Once the data 
are correctly plotted with respect to time {.see figure 26). they are more correctly seen as 
clustered groups of data, not equally spaced in time. 

The plot in Figure 26 indicates a patient population of 8,200 at 1200 on May 16. 2003, that 
would increase to 1 1,000 persons on May 17, 2003, (compared to 7,2(X) in the previous figure). 
Similarly, the estimates of the dead. 1.700 increasing to 2.200 on May 17. 2003, are significantly 
different than the original estimates shown in figure 25. In fact, if the estimates in figure 25 had 
been used, they would have underestimated both the patients and dead by approximately fifty 
percent for May 17. 2003, the day following the conclusion of the exercise. While this approach 
overestimates the number of sick and dead patients compared to ground truth at 1200 on May 16, 
2003, it does give a better sense of the developing scale of the outbreak that would have become 
apparent if the exercise had continued passed May 16. 2003. 


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T2AAR 


T2 


12000 

10000 
v> 

UJ 
CO 

< 8000 
u 
u. 

° 6000 
cc 

UJ 

m 4000 
2000 
0 

5/13 5/14 5/15 5/16 


Figure 26. Correct Plot of Patient Numbers and Dead Numbers Versus Time 
Example 3. DuPage County Emergency operations Center 

The DuPage County Emergency Operations Center (EOC) called in a Geographic Information 
Systems (GIS) analyst to help esiimaie the number of DuPage County citizens who could have 
been at each of the three release sites io the Chicago area. The EOC suggested that this 
information could provide some indicators of which Strategic National Stockpile (SNS) 
distribution sites (located around the county) might be busiest and which hospitals might be 
seeing more patients. The first set of estimates was based upon raw numbers of people from 
specific areas of the county who were at the United Center during the Saturday night game. The 
GIS analyst got this information from the United Center ticket box office based upon zip codes. 
Next, the analyst collected data for the numbers of county resident who ride the single train line 
coming out of Union Station that passes through DuPage County. The analyst used the average 
Saturday traffic on that line and counted the number of people who got off at each station in the 
county. 

DuPage County accounted for one percent of the people who attended the hockey game and for 
fifty-two percent of the people who left Union Station via the train line. Estimates of DuPage 
County-O’Hare traffic were not developed because of limited time and the greater number of 
variables. An estimated seventeen percent of the total people infected at the first two sites were 
from DuPage County. Following his presentation to the EOC. the DuPage County Office of 
Emergency Management said that while GIS is not usually tapped in an emergency response, 
that would have to change based upon how seemingly valuable their skills and data could be. 



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The final report by the DuPage count analyst discussed the methods and results and is quoted 
here in full: 

During the exercise, it came to light that the State of Illinois 
pharmaceutical supply was limited, and we needed to identify’ the 
approximate number of DuPage County residents exposed to the 
biological releases and what portion of the county they reside. 

There were three biological releases in the City of Chicago; Union Station 
(released 8:00 am. United Center (during a Blackhawk's playoff game), 
and O'Hare International Airport (International wing) 

For the Union Station data collected we asked Metro to provide us with 
train ridership information on the Burlington Northern Line for the total 
trips leaving Union Station to DuPage County on an average Saturday. 

Metro provided the totals as well as the breakdown per train station in 
DuPage County. The Burlington Northern Line is also the only commuter 
line in DuPage County that leaves from Union Station. 

The United Center data was provided by the Blackhawk's Director of 
Ticket Operations. The data reflected the last game of the .season, a 
month prior to TopOffl, and was a sold out event. This event would 
provide us with the most accurate information we could have hoped 
possible. The attendance count tva.? provided to us for each zip code 
contained in DuPage County. 

Information was not available for O'Hare International Airport in the time 
frame available. 

These numbers were tabulated and mapped out di.splaying the 
concentrations of potentially infected residents. 

These estimates were calculated to provide the State of Illinois with a 
percentage of potentially infected residents so DuPage County would 
receive the bare minimum amount of pharmaceuticals from the 
underestimated Illinois stockpile. 

The data gathered here reflects DuPage County residents only. Intended 
to provide rough estimates for pharmaceutical acquisition, and to provide 
a general overview of the concentrated areas in DuPage County. For an 
actual statistical analysis, this information would have been passed along 
to an epidemiologist for rate of spread calculations and probability 
modeling. A 3 hour window wa^ given for data collection, tabulation, and 
display. 

Given the parameters analyzed — the final estimate of the total exposed population, of which 
nineteen percent would have been DuPage County residents — was 25,706 persons. The actual 
scenario numbers totaled 21,534 persons, 3,100 in the initial population and 18,434 in the 
secondary population. The advantage to this approach was that it avoided all the significant 
problems in the patient population data and, in addition, provided an estimate not based upon 
projections, merely on normal use data — which is likely to be a better data set, unaffected by 
either exercise play or unannounced real-world attacks. 


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Other efforts 

In addition to the efforts described above, two other efforts were identified that attempted to 
model the epidemic spread. There were also isolated events where decision-makers attempted to 
deal with the uncertainty involved in the response. This section covers all of these isolated 
events. 

Statements were made at the T2 AAC that indicated the Illinois Crisis Action Team (IL-CAT) 
modeled the epidemic. Further information about the results of this modeling is not available, as 
the data collectors in the Joint Operations Center did not capture it. 

The Centers for Disease Control and Prevention (CDC) apparently also estimated the scope of 
the epidemic on the second or third day of the exercise. At the AAC, it was reported that the 
CDC modeled the epidemic using the number of reported cases (from IDPH), the known 
incubation period (two to seven days, normally two to three days), and a rate of transmission of 
three secondary cases per primary case. In actuality, the rate of transmission used in the scenario 
depended upon the site of exposure: .seven secondary cases per primary ca.se at the United Center 
and eight secondary cases per primary case at Union Station and O’Hare International Airport. 

Unfortunately additional data were unavailable to the evaluation team other than what was 
discussed at the AAC. Thus at the time of preparation of this draft report, there is no indication 
about the methods used, the results obtained, or whether decisions were made based upon the 
information. The report indicated, however, that the resulting predictions were within 
approximately ten percent of the final patient numbers. 

In addition to modeling the epidemic outbreak, other estimates were made by officials. These 
“back of the envelope” calculations were important in several decisions, particularly for 
decisions regarding resource allocation. 

At 0915 on May 14, 2003, the Chicago DPH determined that the SNS would be distributed 
according to the city’s and county’s population. The initial planned distributions were: Chicago- 
12,400 doses; Cook-12,500 doses (6,250 Doxycycline, 6,250 Ciprofloxacin); DuPage-1 0,100; 
Lake-6,000; Kane^.4(X). 

The reason that public health officials decided to distribute according to population, versus actual 
number of cases, was they lacked confidence in the accuracy of the number of cases being 
reported. Likewise they did not have a clear understanding of how many patients would 
ultimately be affected in each county. They did, however, know how many potentially affected 
persons lived in each county and saw that as a way to estimate the vulnerable population versus 
the infected or exposed population. 

On May 14. 2003. Cook County DPH needed to know how many persons working at hospitals in 
Cook County would need prophylaxis. Instead of attempting to determine the potentially 
exposed population at each of the 22 county hospitals, Cook County DPH simply took the two 
largest Cook County hospitals, averaged the number of persons who would need prophylaxis, 
and then applied these numbers to the rest of the 22 hospitals. This over-estimated the need for 
prophylaxis, but resulted in a quick answer that would allow the prophylaxis to be distributed. 


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4. Artificialities 

Several artificialities affected the analysis of this subject: 

• The Metropolitan Chicago Health Care Council injected additional, unscripted, patients 
during the early phases of the exercise. These patients were intended to assist hospital 
accreditation. However, they were inadvertently configured to resemble T2 scripted 
patients, resulting in a distortion in the numbers of patients being reported. Because these 
patient numbers were not recorded, it complicates an understanding of how patient counts 
and epidemiological models played into the scenario; and 

• During the exercise some media play was scripted. This meant that some patient 
numbers were reported based upon exercise injects, not the actual numbers of patients 
being reported to decision-makers. One example of this type of reporting occurred with 
the Office of the Governor of Illinois. Ground truth patient counts had been given to the 
Governor prior to the start of the exercise due to an exercise artificiality necessitating the 
pre-taping of top official statements. Using these numbers, the Governor taped several 
interviews or reports incorporating tho.se numbers. However, when they were broadcast, 
the ground truth numbers were significantly different from the patient numbers held by 
the State and local governments and public health authorities. 

5. Analysis 

During the FSE there was significant uncertainty in the patient numbers. Indeed some of the 
artificialities discussed in the previous section may have increased the uncertainty. While the 
artificialities were unrealistic, the chaotic and uncatain environment they produced was realistic. 

Decision-makers and those attempting to estimate the exposed population reacted in a variety of 
ways to the problem of uncertainty in the patient numbers. The methods used by the DuPage 
County GIS analyst attempted to resolve the fundamental conflict they were facing which was 
that the patient data were potentially inaccurate but that they needed accurate predictions of the 
number of infected persons in the county. By knowing the day, time, and place of the release 
and combining this information with demographic, economic, medical, and law enforcement 
data, the analyst was able to make a reasonably accurate estimate without knowing the detailed 
progression of the actual cases of the disease. Participants who chose to use the actual numbers 
of reported cases could be said to be ignoring the uncertainty inherent in the data. Even if they 
knew that the data were suspect, they still used them, as there was no other apparent alternative. 
In these examples, reported caseloads were used in various approaches to develop an estimate of 
how many patients would need treatment. 

Finally, some participants focused on other measures in order to move decisions forward. For 
example, the Chicago DPH decision-makers lacked confidence in both the data they were 
receiving and their ability to use the data to predict how to allocate resources. Instead they 
focused their decision upon the vulnerable population, instead of focusing on the infected or 
exposed populations. 


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6. Conclusions 

This section provides three sets of 
observations and conclusions: 1) one relating 
to uncertainty and how participants dealt 
with it, 2) the information iceberg problem, 
and 3) a more general set of observations of 
how epidemiology played in the various 
EOC operations. 

a. Uncertainty 

From the preceding reconstruction, the 
following was observed: 

• Uncertainty in the patient population 
numbers existed during the FSE. 

Most of this uncertainty was due to 
exercise artificialities, but it is not 
clear that during a real event the 
magnitude of the uncertainty would 
be less, even if the causes were 
different; and 

• It is not the fact of uncertainty that affected exercise decision-making but how 
participants dealt with the uncertainty. By finding data, systems, and methods that 
allowed them to work around the problems with patient reporting data, some participants 
were able to deal with the uncertainly and make informed decisions. 

b. The information iceberg 

There were apparently few attempts to understand the long-range patient load. It is unclear why 
so few attempts were made. Two possible reasons include: 

• Lack of long-term exercise play. Participants may have simply ignored what they did not 
need to worry about; and 

• Lack of confidence in the patient data, and no clear way to model the long-term effects in 
the face of poor patient data. 

The last reason may be the most important for developing a general lesson learned about the 
iceberg problem. The DuPage County GIS analysis was the only documented effort that 
examined how large the problem might be. This analysis was not accomplished using patient 
data but rather relied on an estimate of the number of people who might be exposed in the 
county. 

Finally, decision-makers should be knowledgeable of the information iceberg problem for 
contagious diseases such as plague and especially in cases of potential bioterrorism. It is 
important for them to expect it, look for it, and question their advisors when it is not brought to 
their attention. 


Sl'.MNURY OF CO.NCLL'SIONS — 

Decision-Making: 


The extent of the affected population will always be 
uncertain in a bioterrorism incident. Public health 
officials and decision-makers use epidemiological 
models, informed by the threat environment, to help 
determine the scope of the problem. 

During the FSE, few attempts were made to understand 
the affected population. The DuPage County GIS 
analysis was the only documented effort that 
examined how large the problem might be. 

To alleviate .some of the inherent uncertainty, model 
predictions and patient data should be coordinated 
among agencies and across jurisdictions. In 
addition, data collection should be better executed 
than was observed during the FSE. 

By finding data, systems, and methods that allowed 
them to work aniund the uncertainty, some officials 
were able to make more informed decisions. 


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c. Other issues 


These is a set of observations that arose from the work discussed here, but do not relate to either 
the problem of uncertainly or the epidemic profile. 

Information sharing 

Once model predictions and patient data are acquired they should be shared with everyone 
involved in the operation. In fact, information about some modeling efforts was only shared 
among all the participants during the AAC. There is no evidence that any of the results of these 
models were provided to other operations centers during the FSE. 



The DuPage County EOC felt it would have benefited from model prediction? by using them|to 
predict the requirements for and deployment of ambulances throughout the county A senior 
DuPage County EOC watch-stander noted (speaking to a member of the^lllinois CA^^ring the 
AAC), "Why didn’t I know that those predictions were available?” i ^ 


Data collection. 


.\ 


\ 


I UlWAillllUld ’ 


One way to reduce uncertainty and improve the overall fidelitj^f th^dataisno do a better job of 
collecting it. There are systems available, such as the State of Ulinois’ Phase 1 and Phase 11 
disaster reporting system, which could be used to collect patient data as well. This system 
collects bed counts, ventilators, blood suppUesj^^ong other supplies, during a disaster. 
However, the accurate collection of even the existing data requires considerable numbers of 
personnel, personnel that may not be availabi^uringfan,emer£encv. 


\ 




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H. Balancing the Safety of First Responders and the Rescue of Victims 


1. Introduction 

Historically, first responder rescue agencies have 
demonstrated high competency and experiential knowledge in 
managing traditional rescue situations: natural disasters, fires, 
and technical rescue challenges. In the hazardous materials 
(HAZMAT) environment, hazard identification is assisted by 
placard systems, knowledge of shipping contents, pre- 
planning at fixed facilities, and field-testing processes to 
identify common hazardous substances. In such incidents 
when victim survival is dependent upon timeliness of medical 
treatment (referred to as the golden hour), first responders are 
typically attempt to initiate rescue and removal of victims as 
rapidly as possible, while Incident Commanders manage 
responder safety with an ongoing risk-^)enefit analysis. 

However, when faced with a potential weapons of mass 
destruction (WMD) emergency, first responders encounter a 
greater risk of becoming casualties themselves. For example, 
in Top Officials (TOPOFF) 20(X). the first responders to arrive 
after the explosion in Portsmouth, New Hampshire, were 
incapacitated by a persistent chemical agent used in the attack. During the 9/1 1 World Trade 
Center attack, many New York City police and fire fighters died when the towers collapsed. In 
addition, first re.sponders may be faced with delay^ identification of toxic substances, the 
potential existence of secondary explosive devices, and other unknowns. Under these conditions 
of additional danger and uncertainty, consideration of risks and benefits in the development of 
action plan.s becomes more challenging. If victims are in immediate need of rescue, the initial 
action plan may reflect best guess/best practices information, placing responders in a rescue 
mode. However, as more information becomes available, plans can change and rescue 
operations may come to a halt. This is the scenario that was observed at the Seattle radiological 
dispersal device (RDD) site during the Top Officials (TOPOFF) 2 (T2) Full-Scale Exercise 
(FSE). 

During the FSE. a number of public health officials and data collectors at the incident site, many 
of whom were subject matter experts (SMEs), expressed concern about the time it took to triage, 
treat, and transport victims. Commentators on the Virtual News Network (VNN) also raised this 
concern. Given the uncertainly surrounding the explosion, particularly when many of the 
responders artificially had the knowledge that it was a radiological incident, the Incident 
Commander had to take precautions to ensure that the responders were safe. This Special Topic 
focuses on the issues surrounding the balance of responder safety and victim rescue. 

2 . Background 

a. Interagency communication 

In large-scale incidents and exercises, communication between agencies is typically the largest 
command and control challenge. Command decision-making and development of an integrated 




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incident action plan are enhanced by effective communication links between the various agencies 
on the ground. The ability of a local Incident Commander to use information (e.g., radiation 
exposure levels, plume modeling, and toxic agent identification) provided by State and Federal 
responders depends on rapid and effective communication. With more detailed information, the 
incident action plan and the related risk-benefit analysis evolves with increasingly greater 
accuracy. 


During the 9/11 terrorist attack on the Pentagon, the Arlington County (Virginia) Fire Chief 
managed his resources on the scene with a number of local and Federal agencies. He stated, 
“They [the other agencies] understood their role, which was to help the fire department move the 
incident through its various phases.” Avoiding duplication of effort, the Arlington County 
Fire Chief put the Federal responders to work assisting the Fire Department, For example, he 
used Federal resources to set up chain-link fencing and scene security in order to isolate the 
scene. These types of decisions allowed local and Federal agencies to work together and solve 
incident problems rapidly. He also staled, “Having a relationship with key officials prior to the 
incident does make a difference. We worked regularly with our military personnel, our Federal 
Bureau of Investigation (FBI) and Federal Emergency Management Agency (FEMA) personnel. 
You have to work on those relationships before the incident, not during the incident.”'"' 

b. Risk'benefit analysis 

The use of risk-benefit analysis is common in first responder incident command systems for 
routine responses, and is likely even more necessary when responding to a possible terrorism 
event. With the potential use of WMD and secondary explosive devices, it is imperative to 
maximize the safety of first responders to avoid having them become victims themselves. 

Fire departments typically maintain a definite posture towards life safety and rescue. For 
example, Montgomery County (Maryland) Fire Rescue (MCFR) has a systematic approach to 
risk-benefit analysis. Their policy stales, “Saving live victims is the rescue mission, while 
minimizing the risk of harm to the rescuers.”’’^ This does not mean that fire and rescue 
operations are suspended until all possible risks are defined in detail; the objective of the first 
responders remains saving as many lives as possible. In the event of a chemical attack, MCFR 
policy cautions first responders “not to ‘automatically’ assume that the incident involves super 
toxic chemical agents.” For the Phoenix Fire Department (PFD), risk-benefit analysis means 
that when victims are present all first responders are to move forward with standard operating 
procedures unless a secondary device is present. However, if no apparent victims, life hazards, 
rescue situations, or threatening fires exist, fire department personnel should not be exposed to 
risk. PFD policy states that in this situation “first arriving units should secure a perimeter, 
evaluate the situation, and await the arrival of the Hazardous Materials Technicians.”'* 


Elliott, Timonthy. “First Responders. Feds Join Forces.'* Fire Chief December 2001. Fire Chief Magazine. 
July 8, 2003. 

Ibid. 


‘ Montgomery County. Montgomery County, Maryland Fire and Rescue Service. Managing the Consequences of 


a Chemical Attack: A Systematic Approach to Rescue Operations . Montgomery County: Maryland, 2001. 


^ City of Phoenix. Phoenix Regional Standard Operating Procedures. Hazardous Materials Weat)ons of Mass 
Destruction Chemical. Biological. Radiological. Phoenix: Arizona, 2000. 



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The first step in conducting a risk-benefit analysis involves assessing the disaster scene and 
gathering vital information. The early stage of information collection can include field 
reconnaissance (recon). Initial recon is viewed as a key factor when deciding if the rescue is a 
“Go” or “No-Go” situation. Ongoing data collection through recon provides the Incident 
Commander with the information needed to make accurate decisions regarding risk and 
resources. In a presumed WMD situation, the recon team is not sent to help victims; instead, 
their mission is to establish how many victims, the type of incident, and the level of risk involved 
with the incident. This information helps guide commanders in determining how to address the 
incident, and best save lives. However, it also means that the response time to triage, tteat, and 
transport is necessarily longer than during a non-WMD incident. 

c. Personal Protective Equipment 

A significant component of an initial action plan is the determination of appropriate Personal 
Protective Equipment (PPE) for responders. Because time, distance, and shielding are important 
means for protecting responders from the exposure to gamma radiation, training is also a 
necessary pre-cursor to the response to incidents involving radiation. 

The recon team is the first to move into an operational area. Therefore, it is imperative that they 
are equipped to handle any level of risk so that they can safely report back to the command post. 
MCFR policy is that the recon team wears the best available protective clothing with standard 
firefighting breathing apparatus: 

For initial on-scene quick rescue of Ih'e victims, first responders should 
wear their turnout gear, self-contained breathing apparatus (SCBA), and 
butyl gloves. However, later into the incident and where rescue may still 
he required, first responders should wear Level B Protection or the 
appropriate chemical siut as indicated by the site safety plan. 

The Boston Fire Department has similar guidelines regarding PPE. When Boston’s first 
responders arrive on the scene of a presumed chemical attack, guidelines require them to don all 
PPE equipment available before entering the contaminated site.'*’** 

There has been much controversy on the best way to protect response units, especially when 
dealing with unknown agents in the opening hours of a response. In 1999, the Soldier and 
Biological Chemical Command (SBCCOM) issued guidelines for Incident Commanders’ usage 
of PPE. While some departments fell these guidelines were useful, more than half of the fire 
service survey re.spondents said they would not sanction SBCCOM guidelines and would have 
developed their own PPE guidelines.’*’’ Some departments, including MCFR, have adopted 
selected SBCCOM techniques into their own guidelines. For example, MCFR instituted the 
usage of portable fans to help ventilate buildings where chemical agents may be present.”*"' ' 


Montgomery County. Montgomery County, Maryland Fire and Rescue Service. Managing the Consequences of 
a Chemical Attack: A Systematic Approach to Rescue Operations . Montgomery County: Maryland, 2001. 

City of Boston. Standard Operating Procedure No. 61. Operations and Response to Terrorist Incidents . Boston: 
Ma.ssachusetts. 

Peterson, David F. ‘Terrorism and Turnouts: The Controversy.” Fire Engineering . March 2002. Fire 
Engineering Magazine. 

' SBCCOM test results showed that 50-70% of chemical concentration can be decreased when the portable fans 
are used. 


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Specialized protective equipment matched to hazardous substances is ideal but is currently not 
likely to be available in a timely manner or in quantity enough to accomplish victim rescues in 
most hazardous environments. 

d. Secondary explosive devices 

Terrorists can employ a number of tactics to inflict as much damage as possible. One strategy 
used by terrorists is the use of a delayed secondary explosive device. The purpose of such a 
device is to injure or kill first responders. Typically, these devices are hidden near the original 
incident. 

Secondary explosive device awareness has become policy and is accounted for during first 
responder training throughout the world. Most first responder units understand the need to watch 
out for these devices. A review of several fire rescue policies indicates that even if secondary 
explosive devices are suspected, rapid intervention and victim removal still remains the ultimate 
goal. If secondary devices are found, response units are directed to immediately pull back and 
wait for specialized explosive ordinance disposal a.ssets. For example, the PFD has a simple yet 
precise procedure addressing awareness of such devices. The first arriving units are expected to 
establish command and begin sizing up the situation. While responding, they are to: 

...be aware of secondary devices designed to injure additional victims and/or first 
re.sponders. Upon sighting a device that appears operable, [personnel are 
instructed to withdraw] until Police Bomb Squad has inspected/rendered safe any 
su.spicious appearing device.' 

MCFR and the Denver Fire Department both have similar response methods."'^'"* 

It is also useful to examine the emergwtcy response policies of Northern Ireland and England. 
Their use of incident command and risk-benefit analysis has proven successful over decades of 
domestic terrorism response experience. The Northern Ireland Fire Brigade maintains an 
awareness of potential secondary device placement, avoiding command post locations near 
dumpsters and parked cars, where such devices may be hidden. Arriving bomb technicians 
sweep the command post areas first, eliminating the possibility of additional explosives."'^ The 
United Kingdom Home Office Strategic National Guidance also emphasizes the need to sweep 
command post and support areas for the presence of secondary devices."* 

3. Reconstruction 

The evaluation team did not obtain specific data describing the incident commander’s risk- 
benefit analysis process. However, it did obtain data describing the response, which is the focus 
of this reconstruction. Figure 27 depicts a timeline of the key events during the rescue phase at 


' ' ' Montgomery County. Montgomery County, Maryland Fire and Rescue Service. Manatzing the Consequences of 
a Chemical Attack: A Systematic Approach to Rescue Operations . Montgomery County: Maryland, 2001. 

City of Phoenix. Phoenix Regional Standard Operating Procedures. Hazardous Materials Weapons of Mass 
Destruction Chemical. Biological. Radiological . Phoenix: Arizona, 2000. 

' Montgomery County. Montgomery County, Maryland Fire and Rescue Service. Managing the Consequences of 
a Chemical Attack: A Systematic Approach to Rescue Operations . Montgomery County: Maryland, 2001. 

"■* City of Denver. City and County of Denver Emergency Operations Plan . Denver: Colorado, 2002. 

Langtry, John. Assistant Divisional Officer. Northern Ireland Fire Brigade. Telephone Interview. July 16,2003. 
United Kingdom Home Office. Strategic National Guidance. The Decontamination of People Exposed to 
Chemical. Biological. Radiological or Nuclear (CBRNI Substances or Material . United Kingdom. February 2003. 


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the RDD site. It was constructed using the observations from data collectors at the incident site. 
All times are noted in Pacific Daylight Time (PDT) unless otherwise specified. 


* 1208: Explosion 

I 1210-1212: First response assets arrive 
I 1213-1225: SFD & SPD gather walking wounded 
H 1220-1235: SFD & SPD initiate rescue operations 
' 1225: Triage station being set up 

1230-1300; Lots of confusion and complaints among injured about lack, of help 
* 1230: HazMal Unit 77 confirms radiation at the site 
I 1237-1245: Gross decontamination area set up 
1 1253-1255: First victim through gross decon 
* 1300: First victim at treatment area 

' 1305: Gross decontaminatioo overwhelmed; advised medical group 
* 1320: First red victims taken to hospital 

1320-1430: Rescue operations cooiioue— many victims unaiiendad and asking for Mp 
' 1333: Manpower arrived and tasked to assist medical group 

1430-1015: Multiple bomb threats cause rescue opentlions to pauM 
1 1615-1625: Oecoolamination and rescue efTtMs restarted 
* 1635: First patient extracted from nilAte pile 
* 1644: Triage started at the rubble pile 

1630-1700: Several unattended victims in the open and in vehicles 
* 1715: Rubble extraction team tnalQ'ogplan lo breach concrete 
1800: First rescue in breached concrete hole * 

1850: Sdll IS patients to be extracted * 

1930: Rubble extraction continues: 4 victimti remaining * 

2020: Three victims remaio in rubble pile * 

2101: One victim remains in rubble pile * 

2111: Last vtclim recovered * 

2250: Search operations to cease * 


I op|rat>ons 


1200 1300 1400 1500 1600 1700 1800 2000 2100 2200 2300 2359 


Figure 27. Reconstruction of Rescue Operations at the Radiological Dispersal Devise Site 


Incident site observations indicate that within minutes after the simulated RDD explosion on 
May 12, 2003, police cruisers, fire engines, and ambulances arrived at the scene. The 
responders, in particular Seattle Police Department (SPD) personnel, first gathered all walking 
wounded and removed them from the scene. SFD repeatedly made announcements over the loud 
speaker tnstructin| anyone who could walk to slowly approach Engine #2 and that help was on 
the Way. SPD was observed searching through the rubble and vehicles, administering first aid. 
and directing victijlhs to Engine #2. SFD was also observed using ladders to get victims nut of 
buildings. All of these events occurred within 14 minutes of the explosion. 

Observations of the response took on a different tone after 1222"’ when the first reports of 
radiation reached the incident site. HAZMAT arrived at 1227 and immediately started to lake 
readings. There was much confusion at the incident site with several accounts of victims crying 
for help with no response from rescuers. 


' All times Pacific Daylight Time. 


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At the same time that HAZMAT was taking initial readings, SFD was also setting up triage, 
treatment, and decontamination stations. According to logs from data collectors observing the 
incident site, a triage station was being set up by 1225, a treatment station was set up by 1243, 
and a decontamination station was set up between 1237 and 1252. The first victim was moved 
through the decontamination station at 1253, and the first victim was observed at the treatment 
station at 1300."^ At 1305, the decontamination station reported that they were overwhelmed 
with victims. There was no indication that they got any assistance until 1333, when additional 
personnel arrived and were tasked to assist the medical group. 

During a typical mass casualty incident, victims are tagged with colored tape or paper based 
upon the extent of their injuries. Victims with red tags have life threatening injuries and require 
immediate care. Victims with yellow tags need treatment but could sustain a short delay. 
Treatment of victims with green tags can be delayed until the more seriously injured victims 
have been cared for. Figure 28 shows the times that victims with red, yellow, and green tags 
were transported from the incident site to a hospital according to data obtained from hospital 
control. The first two red victims were taken at approximately 1315.',^“ From 1315 to 1508, a 
steady stream of victims was taken to area hospitals. From 1315 to only the more serious 
red and yellow victims were transported, and then from 1424 to 1508 mosfly green victims were 
taken to the hospital. This suggests that there was a lull in the response and no seriously injured 
victims were rescued and taken to the hospital. In fact, rescue operations had periodically been 
delayed due to reports of sniper sightings and potential secondary explosive devices prior to 
1430 and were halted at approximately 1430 because a secondary explosive device was found at 
the incident site. 

Rescue, treatment, and decontamination operations started again between 1615 and 1630, and as 
shown in figure 28, victim transport was restarted at 1638. Mostly red and yellow victims were 
taken to area hospitals between 1638 and 1814, at which time hospital control ended operations. 
The data show that prior to the pullba^ at 1430, a red or yellow victim was transported every 
3.4 minutes; after rescue operations resnjmed the transport rate increased to one red or yellow 
victim transported every ‘fi^mimtes. uys not clear what led to an increase in rate of victims 
transported. 


' The evaluation team ha.s no data indicating the level of activity at the triage station at this early stage of the 
response, and no data indicating when the triage station was operational. 

' The evaluation team has no data indicating the severity of injuries for the victims moving through the 
decontamination and treatment stations at this early stage of the response. 

Note that the data do not indicate if these patients were the first patients to go through decontamination or if the 
red patients went through decontamination at alt. 


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ra 


■D 

0) 

t 

o 

a. 

</) 

c 

n 


M 

.1 

O 

> 


110 
105 
100 
95 
90 
85 
80 
75 
70 
65 
60 
55 
50 
45 
40 
35 
30 
25 
20 
15 
10 
5 


• Red Victims 
Yellow Victims 

• Green Victims 

• Total 

X Explosion 




Rescue operation halted on 
site due to bomb threats 

^ ► 


I* 


V 


• I* 




43 






IIMIMI#*** ^ 


18 


K ♦ * A* a • 




0 i-X 

12:00 12:30 13:00 13:30 14:00 14:30 15:00 15:30 1603 16^0 ITSPO. 17:30 18:00 18:30 

Time on May 12 ^ 

Figure 28. Transport of Victims from Incident 

According to data obtained from Harborvioff JHosp)^!. which was hospital control during the 

exercise: ' ' 

\ ' 

• A total of 109 victims were transported to area hospitals during the time that hospitals 
participated in the exercise: 48 red, 43 yellow, and 1 8 green victims; and 

• At the beginning of the exercise, 150 volunteers were placed in the incident site. 
Therefore, 41 victims remained on the incident site when hospital play ended. 

However, the log kept by ho^iial control differs with the tracking data kept by exercise control. 
According to exercise control: 

• A total of 1 15 victims were transported to area ho.spitals: 34 red, 46 yellow, and 35 

green; 

• Responders rescued an additional 13 victims too late to be processed by the hospitals. 
These victims were still loaded into ambulances, but taken directly back to Union 
Station; and 

• An additional 22 victims were not rescued until after hospital exercise play ended. 


The evaluation team was unable to determine why there was a discrepancy in the two logs. 
Possible explanations include: 


Data fri)tu Harborview Medical Center Ma.ss Casually Incident Patient Tracking Log and Seattle King County Public Health Incident 
Log. 


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• Exercise control assigned an injury status to each of the victims at the start of the 
exercise. Responders may have re-classified victim status during the course of the 
exercise; 

• It is possible that there were additional victims transferred to area hospitals from 1511 
to 1608 when hospital control was temporarily transferred to Overlake Hospital; and 

• It is possible that the 13 victims recorded by exercise control that were processed and 
transported to Union Station after hospital control ceased operations were not 
recorded by hospital control. 

4. Artificialities 

During the FSE, a number of artificialities affected how players responded to the RDD incident, 
as well as some players’ perceptions of the response and are, therefore, factored into the analysis. 
The artificialities included: 

• Responders were at an advantage because they knew that the scenario involved an 
RDD explosion. Furthermore, many responders were aware of the concerns that 
came out of TOPOFF 2000 and other real world or exercise events — that responders 
went into an incident site so quickly they became casualties themselves. Therefore, 
during the FSE, many first responders did not rush into the scene when rescue 
operations began, 

• Exercise control expected to have 200 moulaged victims for the exercise. Based upon 
initial planning for the exercise, hospitals expected ninety percent of all victims to be 
transported by 1800. This translates to 180 victims transported. However, there were 
50 volunteer no-shows on the morning of May 12, 2003, so there were only 150 
moulaged victims. Hospital control was not aware of this change. So they were 
expecting more patients than were available; this may have exacerbated medical and 
public health concerns about the overall rescue. 

5. Analysis 

Observations from the incident site from the first hour after the explosion indicate that after 
radiation wasjdetected, responders were held back while HAZMAT teams conducted an initial 
assessment of the situation. While hospital control was aware that radiation had been detected at 
the incident site, there is no indication in the data collector logs that incident command or the 
medical group at the incident site communicated with hospital control to explain the need to 
conduct a more detailed risk-benefit analysis before rescue operations could commence. 

After the first hour, the response became more typical — victims were pulled out of the incident 
area, assessed, and transported to the hospital based upon the severity of their injuries. However, 
rescue and decontamination operations were ^periodically halted and eventually ceased for almost 
two hours due to secondary bomb threats.'"" This caused a similar delay in the transport of 
victims to area hospitals. There is no evidence in the data collector logs that indicated hospital 
control or the individual hospitals were aware of this delay. Similarly, there are no data from 
data collectors at the incident site indicating that the medical group or incident command 


This delay would likely have been even longer if exercise control had not injected that the secondary explosive 
device was far enough away that it would not impact rescue operations. 


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communicated with hospital control about the discovery of a secondary explosive device. After 
the FSE, a hospital controller confirmed that the hospitals were unaware of the secondary 
explosive device. 

6. Conclusion 


Rescue operations at the RDD incident site 
during the FSE highlight the need for 
incident command and hospital control to 
communicate with each other during an 
emergency, especially one involving WMD. 
The public health and medical communities 
should be made aware of the need for 
incident command to conduct a detailed risk- 
benefit analysis prior to the start of rescue 
operations. These communities also need to 
be aware of the actions rescuers will take if a 
secondary explosive device is found and the 
impact that will have on victim rescue and 
transport. In addition, incident command 
must communicate with the public health 
and medical officials so that they understand 
the situation. 


Str.viNUR^ OF Conclusions — 
Balancing the Safety of First Responders and 
THE Rescue of Victims: 


Operation.s at the RDD incident site highlighted the 
need for robust communications between hospital 
control and incident command. 

The medical and public health communities need to be 
educated concerning the activities that first 
responders will take when faced with a potential 
terrorist incident involving WMD. 

Public information personnel from the first responder, 
medical, and public health communities should also 
be educated about expected emergency response 
procedures so that the media and, therefore, the 
public are given one consistent mes.sage during an 
incident. 


While it didn’t occur during the FSE, it is extremely likely that in a real-world emergency the 
media would have become aware of^^ delay in trmsporting victim.s to hospitals. Without a 
concerted message from the public healtBl and r estxmder communities concerning the need to 
balance responder safety and victim rescue^^ublic outcry could have ensued. Therefore, 
public information personnel from both of these communities need to be educated about 
expected emergency res ponse pr(x:edures during a mass casualty incident, especially one 
involving WMD. In addifioi^iW 3 j|al^ nTed to be kept informed by their respective leadership 
to ensure a consistent message^is presSTted to the media and the public. 



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VI. ANALYSIS OF THE SIX CORE AREAS 


1. Introduction 


These six core areas of analysis were identified early in the Top Officials (TOPOFF) 2 (T2) 
planning phase by reviewing the TOPOFF 2000 After Action Report (AAR), lessons learned 
from 9/11 and the following anthrax attacks. Federal, State, and local participant objectives for 
T2, previous weapons of mass destruction (WMD) exercise AARs, and WMD training materials. 
Although the issues differed somewhat in content and presentation, they displayed considerable 
underlying similarity, and naturally clustered into six core areas of analysis. While these areas 
are closely interrelated, they are distinct. Viewing the exercise in light'of^ihese'^ areas provides a 
useful organization of observations and ideas. 

These areas of analysis include: 

• Emergency public policy and decision-making; 

• Emergency public information; 

• Communications, coordination, and con 

• Jurisdiction: 

• Resource Allocation; and 

• Anticipating the Enemy. 

Because emergency public information:i^played"^h a central role in each of the pre-Full-Scale 
Exercise seminars, as well as the Full-Scale Exercise (FSE), particular emphasis is placed upon 
this area. 




V 


2. Instances of challenges and'goodjpractices 

In the various^^ilding-blocl^eminars and the Large-Scale Game (LSG) leading up the FSE, 
several issues, challenges, Emerged that are relevant to the six core areas of analysis. In 
addition, a- number of potential good practices were identified by seminar and LSG participants. 
During and subseque^to the FSE, the evaluation team identified instances of these challenges 
an^^ood praciiceyrim occurred during the exercise. Instances are defined as occurrences that 
^laye3h)ui during the FSE. In several cases, challenges and good practices arose during the FSE 
that were^not anticipated by the seminar and LSG participants. These were identified and 
catalogued^ the analysts as well. 

For each core area, a brief introduction and background are provided. This allows for an FSE- 
based context, such as key events and challenges that occurred within the areas, for discussions 
of the area. This is followed by a discussion of the key challenges and good practices in which 
feedback from the seminars and the LSG is examined and compared to the issues that arose 
during the FSE. Finally, conclusions are drawn and suggestions are made as to how these issues 
could be tested in future exercises. 


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A. Emergency Decision-Making and Public Policy 


]. Introduction 

Public policy and decision-making during an emergency differs from day-to-day policy and 
decision-making. The difference is even more significant during an emergency as a result of a 
terrorism attack. In such emergencies, top officials face especially difficult, political decisions 
under conditions of uncertainty characterized by unknown, or changing, information-baselines. 
For example, public health considerations might make quarantine a seemingly obvious choice. 
But, as was observed regarding Top Officials (TOPOFF) 2000 by Biodefense Quarterly in 
September 2000: 

Decisions regarding patient isolation, travel advisories, home curfews, the 
closure of airports and highways, and attempts to “quarantine ” cities and 
stares must be balanced against the practical feasibility of such measures, 
and their implications for civil liberties.'^^ 

This area examines the unique challenges, difficulties, and nuances of decision-making and 
policy-making in the initial aftermath of a terrorist weapons of mass destruction (WMD) attack. 

2. Background 

Despite foreknowledge of the scenario by some but not all, top officials and other decision- 
makers faced numerous challenging decisions throughout the course of the exercise. Some of 
these decisions are provided in Table lO.'"'* 



Inglesby, Thomas, Grossman, Rita, and O'Toole, Tara. “A Plague on Your City; Observations from TOPOFF,” 
Biodefense Quarterly, Volume 2, Number 2, September 2000. 

Decisions shown do not necessarily represent every decision made by top officials in these jurisdictions, but 
rather a sampling of the primary emergency public policy-related decisions. 


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Table 10. Examples of Emergency Public Policy Decisions Faced during T2 


Washington Venue 

ll.I.INOLS VENIT. 

Federal Agencv/Executive 

• Determination of shelier-in-place 

• Determination of protective action guidelines 

• The elevation of the seven-city alert 

order. 


(PAG) for containing the plague (shelter-in- 
place) by slate officials. 

level to Red by the Department of 
Homeland Security (DHS) based 

• Issuance or mayoral ana county 

upon the radiological dispersal 

proclamations of civil emergency. 

• Issuance of mayoral and county proclamations 

device (RDD) attack and 

• Issuance of mayoral and county 

of civil emergency. 

intelligence. 

delegations of authority. 

• Issuance of mayoral and county delegations of 

• The elevation of the national aleil 

• Issuance of uovemor proclamations 

authority. 

level to Red by DHS based upon 

of state of emergency. 


• Issuance of governor proclamations of stale of 

the RDD and bioterrorism attack. 

• Governor's request for Presidential 

emergency. 

• Presidential Declarations of Major 

Declaration of Major Disaster. 

• Governor's request for Presidential 

Declaration of Major Di.saster. 

Disaster and Emergency in the 
stales of Washington and Illinois, 

• Implementation ot exclusionary 
zone by city officials. 

• Closure/re-opening of the road system by 
Illinois Department of Transportation (IL 

respectively. 

• Declaration of a Public Health 

• Clo.sure/re-opening of road system 

DOT). 

Eflicrgency by the Secretary of the 

by Washington Department of 

Department of Health and Human 

Transportation (WDOT) and city 
authorities. 

• Executive Order #3 - suspended pharmacy 
practice act to let non-pharmacist to dispense 
prophylaxis and to do so outside of 

Sei vices. 

• Closure of airspace by 

• Implementation ol food control 
zone by state officials. 

pharmacies. 

• Executive Order #4 - aulhoization to 

DOT/Fcderal Aviation 

Administration (FAA). 

• Determination ot protective actions 

implement quaroatiuc. 

• Federal restrictions on food 

under condition Red by all affected 

distribution by regional Federal 

Jurisdictions. 


• Determination of prt^live actioiis uider 
condition Red by all ufTected jurisdictions. 

Drug Administration. 

• Evacuation irom shelter zone by 

• Re-opening of airspace by FAA. 

city, county, and state officials. 

• Determine priorities for distribwion of the 


• Controlled re-entry to exclusion 
zone by emergency workers and 
members of public. 

Strategic Nattonel Sitxkpile (SNS) by Illinois 
State. 

• Re-opening of roads by IL DOT. 


• "Initial return" by state officials to I 
allow people to return home in arev ' 

• Medical decittuns: 


that did not appear to be affected by 

— wbeie to move critically ill, versus exposed, 
versus worried-well, versus other patients. 


bla.st. 1 

• Radiological remediation and 
recovery criteria 

— whether to convert specific rooms or an 
entire building to negative pressure, if the 
capability exists. 

— determination of how long patients should 
slay at hospitals. 

— determining how patients would get home 
when discharged under condition Red. 



3. Discussion of challenges/good practices 

In the seminars leading up to the Full-Scale Exercise (FSE), Top Officials (TOPOFF) 2 (T2) 
participants identified numerous challenges and some good practices related to Emergency 
Decision-making and Public Policy. Almost all of the challenges and good practices were 
observed during the FSE. This is additional evidence that foreknowledge of the scenario in an 
exercise does not necessarily result in foregone conclusions. While all the core areas of analysis 
in T2 are interrelated, the area with the greatest impact on emergency decision-making is that of 


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Communication, Coordination, and Connectivity. The ability of decision-makers to obtain or 
discern reliable, validated, timely, and understandable information to inform their decision- 
making emerged as a primary challenge throughout the exercise. 


Table 1 1 depicts the challenges, and good practices relevant to Emergency Decision-making and 
Public Policy that arose in the seminars, as well as the instances that show how these issues 
played out during the FSE. Instances are occurrences experienced by participants during the 
FSE that indicate challenges or good practices associated with particular issues. In the table, a (- 
) is used to indicate challenge, and a (+) indicates a good practice. A ( ) is used to indicate a 
neutral observation in the FSE — one that is neither a good practice nor an issue. Good practices 

] 25 

are those practices that players felt were effective, or which the data indicate worked well; 
these practices could potentially be explored further or promulgated on a broader scale. 
Challenges are examples of the T2 response that were difficult for the responder community and 
that had significant impact on decision-makers. Challenges do not'imply wrong actions or 
incorrect responses by any organization or the community at larg^— this After Action Report 
(AAR) and the analysis as a whole did not focus on evaluatinaright and wrong actions. 
Challenges require the continued attention of the national^ resj)pns^^mmi5iity to facilitate 
smoother responses in the future. 




V 


References in the table are based on specific references in the data. Just because something is not specified as a 
good practice does not mean it did not go well in participants' opinions or did not happen. 


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Table II. Emergency Decision-Making and Public Policy Issues during T2 


Issues 

Semisaxs/LSG 

FSE Insta.nces 

Good practices and CHAi-t-ENOES 

Emergency Public 
Infonnaiion 

Radiological 
Dispersal Device 

s 

*C 

1 

& 

Direction & 
Controi 

Large-Scale Game 
Consequences 

a. Understanding what decisions need to be 
made and by whom. 


✓ 

✓ 

✓ 

V 

See “JurisdictioifiKore Area 

{+) Washington StatwEmeKency ^ 
Operations Cent« (E(5&gtempted to 
us4<teffM^ecisipnatKMi^s. 

(-t-^eattle ^B^representatives cross- 
fei^l^d decista^. 

Som|j^cnaitiy in road re-opening 
^anihoaii^^^' 

^rjl'^mc uncertainly in airspace re- 
lopenlbf authorities. 

(\Some uncertainty in authorities to re- 
open facilities where plague was 
released. 

b. Making decisions under conditions of 
uncertainly; accuracy versus timeliness of 
decisions. 



V' 


✓ 

(+) Radiological dispersal device (ROD) 
site leaders recognized that decisions 
needed to be made without all 
information. 

( ) The sheller-in-place zone had to be 
expanded in Washingion. 

( ) Discussion on size of exclusion zone. 

( ) Road openings in Washington would 
likely have had to be re-closed due to 
plume. 

( ) First responders in Washington held 
back on victim rescue pending 
preliminary risk-benefit analysis. 

c. Hjril^ing intemationd im^tiations of 
declSbas (transportatior^ Mnnty. etc.) and 
^avin^buistency in d^Kt’ons across 
borders, 

✓ 

1 

1 

✓ 

✓ 

(+) Numerous instances of Department 
of Homeland Security (DHS) and other 
agencies interfacing with international 
authorities. 

d. Making the notable, politically charged 
decisions (quarantines. Strategic National 
Stockpile (SNS) distribution, etc.) and how to 
handle them. 


1 

1 

✓ 

✓ 

0 Officials in Chicago suggested 
requiring proof of presence at one of the 
release sites to receive prophylaxis. 

( ) (Juarantine was considered in Illinois. 

( ) Whether other countries could access 
the stockpile was considered. 


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LSSl'ES 

Semisars/LSG 

FSE iNSTANChS 

Good practices and challenges 

Emergency Puhlic 
Informalion 

Radiological 
Dispersal Device 

Bioterrorism 

Direclioii <& 
Conirol 

Large-Scale Game 
Consequences 

e. Management of economic impacts of 
increased security measures. 




✓ 

✓ 

(+)lnfonnaiion Analysis^^J^ 
Infrastructure Fhptection DirectWate in 
DHS examined ecwomic impa^tf 
nationwide alerra.^TL 

(+) AgeiK'ies at all lev^M^umented the 
profeMatf^onortic i»ee^^f security 
m^sures]^^^ 

f. Understanding the extent to which the 

Threat Condition Red changes every aspect of 
decision-making- 

1 

1 

1 

✓ 

1 

, (-)^>si agenci^l^ere uncertain what 
^^iora^^ke in response to an 
' etevaUDnwtt»nomeland Security 
A®^wry System to Red. 

g. Handling/undersianding long-term 
restoration impacts. 

■ 

■ 

■ 

■ 

✓ 

^A. ?loi played. 

\ 



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a. Understanding what decisions need to be made and by whom, and knowing who to have 
at the table 

This issue is inherently related to the core area of Jurisdiction (See the “Jurisdiction” Core 
Area), but it has significant implications in the arena of emergency decision-making. Emergency 
policy decisions in the aftermath of a terrorist WMD attack are challenging enough, but not 
knowing who has the authority to make what decisions adds tremendously to the challenge. 
Such uncertainty not only impacts public relations (to the extent it increases the chances of 
inconsistent messages going out, or messages that may need to be altered later), but it also 
multiplies the inter-agency coordination burden as agencies feel their way through the process 
under the pressure of an unfolding disaster. 

The Jurisdiction core area examines the jurisdictional uncertainties that participants experienced 
during the exercise, almost all of which arose in the context of decisions. Transportation 
emerged as a primary area where many were not aware of the various authorities for closing and 
re-opening elements of the nation’s transportation system, including roads, airspace, the rail 
system, and ports. Other issues where decision-making was unclear included Homeland Security 
Advisory System (HSAS) threat elevations (see the “Alerts and Alerting” Special Topic), and re- 
opening the facilities in Illinois where plague was released. 

Another issue faced by decision-makers is not always having the right people involved in the 
decision-making process, and sometimes not knowing who the right people are. Both of these 
factors can make the unique challenges of this core area — making difficult policy decisions 
under conditions of uncertainty — more challenging. Likewise, improvements in the decision- 
making process can help reduce the uncertainty in some decisions, and increase the credibility of 
difficult decisions faced during such times. There were instances of the FSE during which 
decisions were not coordinated with all relevant parties. Perhaps the most dramatic example of 
this was when decision-makers at Fedt^al. State, and local (FSL) levels were challenged to make 
policy decisions based upon the potential radiological contamination in the Seattle area. Setting 
aside the difficulties they experienced confirming the extent of the contamination (See the “Data 
Coordination” Special Topic), lop officials needed experts who could translate detailed technical 
data into plain-language to aid them in the policy decisions they faced. 

Not all agencies had the needed technical expertise on hand. In the words of a King County 
Emergency Operations Center (EOC) participant, “translating technical data on radiation into 
meaningful ‘so what’ terms and coordinating this was difficult. It took us three days to find 
someone [decision-makers] could understand.” The Washington State Department of Health 
acknowledged in the venue Hotwash: 

Our biggest policy issue was around data — we were data rich and 
information poor. We did not have one place where highly technical 
data were being analyzed in one place. The result was that different 
policy rooms were making decisions based upon the data they had, 
which were probably right based upon the data they had, but not 
consistent with others. 

Federal resources designed to assist decision-makers in translating technical data into meaningful 
terms were often not effectively utilized during the exercise. For example, the Advisory Team, 
which provides Protective Action recommendation support for decision-makers under the 
Federal Radiological Emergency Response Plan (FRERP), was not accessed by local decision- 


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makers. This struggle to understand the implications of detailed technical data, despite 
knowledge of the scenario by some, demonstrated that decision-makers were not assisted in this 
particular area by knowledge of the scenario. 

The City of Chicago and the collar counties also noted in their Lessons Learned Reports from T2 
the importance of having the right people in decision processes, stating that EOCs must be 
staffed with decision-makers, not just information gatherers. They also noted the importance of 
configuring seating arrangements in the EOC to have similar disciplines grouped together. One 
example of a good practice is that WA State EOC staff appeared to have defined decision 
processes that they used in their decision-making. Designed by the emergency managers who 
work there, the WA State EOC facility floor plan and building design promotes collaborative 
decision-making and information flow with its open floor structure, video teleconference 
capability, and electronic information sharing systems. In addition, a data collector in tite Seattle 
EOC remarked that the EOC appeared to have substantial representation from various disciplines 
on hand to cross-fertilize decisions, and there appeared to be processes by which designated staff 
was empowered for emergency decision-making when the Maycw was absent. 

b. Making decisions under conditions of uncertainty: accuracy versus timeliness of 
decisions. 

The spokesperson for the City of Seattle at the venue Hotwash summarized this issue well when 
he said to the audience, reflecting on his experience from the FSE, “Nothing is static — the plume 
changes, evacuation zones change, etc. A solved problem is maybe only temporary — a final 
decision this hour may be a different decision the next hour.” 

Top officials are routinely challenged in real life to make decisions under conditions of 
uncertainty. In both the Washington and Illinois, decision-makers were faced with the challenge 
of making decisions under conditions of imperfect information. In some cases, needed 
information was forthcoming in time (such as knowledge about whether an outbreak of 
Pneumonic Plague is naturally-occurring or an act of bioterrorism). In others, the infonnation 
was unknown or may be based upon imperfect data, still requiring interpretation. In both cases, 
decision-makers must weigh the relative costs of time — the delay while waiting for the 
information base to improve — against the costs of less-than-perfect information. 

T2 provided opportunities for decision-makers to explore these tradeoffs. The role of the 
Department of Homeland Security (DHS) is to assess the risk of terrorist attacks (a very 
imprecise task by definition), and to implement preventative measures designed to prevent or 
thwart attacks. This is an exceptionally difficult task replete with uncertainty. However, the 
Secretary of DHS cannot afford to wait for certainty to act — certainty for the Secretary of DHS 
is defined as an attack. 

Perhaps the most dramatic decisions that were made during the FSE were those by the DHS 
Secretary to elevate the national alert system to Red first in seven select cities, and then 
nationwide (the City of Seattle and King County both elevated their jurisdictions to Red in the 
wake of the radiological dispersal device (RDD) blast — this is discussed in more detail in the 
“Alerts and Alerting” Special Topic). Of course in the exercise this was notional, and based 
upon notional intelligence. Likewise, in the exercise the real implications of a nationwide red 
alert could not be played. But the decision process and decision tradeoffs that the DHS Secretary 
and the Homeland Security Council (HSC) considered were real. And agencies’ responses, if 


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only to express great concern at the cost of maintaining a condition Red posture given a 
nonspecific threat, were also real. They challenged leaders to refine the HSAS system so that it 
achieves the intended goal of preventing future attacks in a way that, if possible, is more .specific 
to localities at greater risk and minimizes unintended consequences. 

In Washington, many policy decisions were made under conditions of uncertainty. The shelter- 
in-place parameters, the size of the exclusion zone, boundaries of the food zones, and road 
closures all depended on information regarding the size and nature of the radiological 
contamination. In anticipation that decision-makers would receive limited data in the early hours 
following the RDD incident, the Washington Department of Health, Public Health Seattle/King 
County, and the EPA developed default Protective Action Guidelines (PAGs) prior to the FSE. 
The Seattle Mayor implemented these default PAGs during the early hours of the incident, as 
decision-makers awaited the collection of the data required to effectively model the radiological 
contamination. During T2, as in reality, information changed over time, and some decisions had 
to be re-examined. Decision-makers in the WA venue, for example, expanded the shelter-in- 
place parameters once, and held heated discussions regarding the size of the exclusion zone. 
They also confronted the political issues of opening and then potentially having to re-close 
transportation systems ba.sed upon the recognition that they did not have all the information 
needed for these decisions. Operational decisions at the incident site were made in the midst of 
uncertainty, such as how long to wait for confirmation of radiation readings before rescuing 
victims, although it was somewhat influenced by artificiality. During T2, there is evidence to 
suggest responders held back from rescuing victims until a preliminary risk-benefit analysis 
could be done. 

In the bioterrorism attack in Illinois, decision-makers were constantly challenged to make 
decisions under uncertainty. For reasons both of exercise artificiality as well as coordination 
challenges between agencies, tracking patient numbers was extremely difficult. Hospitals and 
the public health community were challenged to anticipate and plan for surge issues that would 
likely overwhelm the public health system within seven to ten days under the scenario. 

And of course, throughout the exercise there was some uncertainty as to whether there would be 
additional follow-on attacks, though this was not aggressively played by most and was not 
specifically designed into the exercise. 

c. Handling international implications of decisions (transportation, security, etc.) and 
having consistency in decisions across borders 

The international scope of T2 was another ground-breaking element of T2 design. Represented 
through Canadian play and notional international injects, this expanded the scope of decisions 
and implications faced by top officials. On the domestic side, there were numerous instances of 
DHS and other agencies interfacing with international authorities in decisions such as 
transportation, food and import restrictions, border security, economic impacts of decisions, 
threat intelligence, and protective action measures. In the National Direction and Control 
Seminar, Canadian representatives stated that they would be interfacing with the Centers for 
Disease Control and Prevention on epidemiological data and tracking. They did just that during 
the T2 FSE. In addition, Canadian officials worked with DHS to place liaisons in Washington 
and Illinois. The DHS Office of International Affairs also coordinated extensively with 
Canadian counter-parts in all aspects of play to include the elevations of the threat condition to 
Red and addressing potential international economic implications of security measures and job 


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furloughs. Interestingly, in the seminar on bioterrorism, participants stated they did not think 
that cancellation of international flights would be likely once the plague epidemic spread 
internationally. This is another example of things not happening as expected during the FSE: 
the first cases of a mysterious illness were being reported from Vancouver as early as May 12, 
2003. Within two days international (and domestic) flights were suspended as the U.S. 
transportation system was temporarily shutdown in Chicago. The Department of State (DOS) 
and Canadian AARs address international implications of the scenario and the lessons learned 
from the FSE in detail. 

d. Making the difficult, politically charged decisions (quarantines, Strategic National 
Stockpile distribution, etc.) 

During T2, decision-makers at all levels faced difficult decisions. The DHS decision to raise the 
red alert was surely a difficult one, and was discussed previously. In another example of a key 
decision, the Governor of Illinois requested a Presidential Declaration of Major Disaster to 
obtain federal assistance through the Stafford Act for the escalating bioterrorisra disaster that had 
its epicenter in Chicago. This request was first denied, likely because it did not qualify under the 
language of the Stafford Act’’ . In the end, this request was approved as an emergency 
declaration — and while purely notional, is nonetheless groundbreaking to the extent it challenged 
traditional interpretations of the Stafford Act. 

Decision-makers in Illinois faced two difficult decisions: The potential need to implement a 
quarantine and how to distribute the limited initial supplies of the Strategic National Stockpile 
(SNS) before the arrival of the Vendor-Managed Inventory (VMl).'^’ While officials never 
publicly used the term quarantine and did not notionally enforce it, the decision was made to 
close down air, sea, and rail transportation and to instruct the public to take a voluntary “snow 
day.” By May 14, 2003, the IL Governor had issued an Executive Order authorizing this and 
other emergency measures, such as releasing patient information to law enforcement and 
allowing licensed medical practitioners to operate outside of normal areas. Another Executive 
Order allowed non-pharmacists to dispense prophylaxis. 

An interesting decision in Chicago was one where authorities required physical proof of 
exposure to one of the three known release sites as a prerequisite for receiving SNS medications, 
to ensure that only the initial exposed population (and its close contacts) received what were 
originally limited numbers of medication. This policy appeared to ignore the problem of 
secondary infections that the city and counties were beginning to deal with at that point, not to 
mention the possibility that other releases were still underway. 

In an example of a good practice, city and state officials proactively acted to implement 
authorities to enable them to take extraordinary measures such as the ability to implement 
quarantine and to let non-pharmacists dispense prophylaxis and to do so outside of pharmacies 
should it be needed. DHS appeared to be researching legal authorities to implement a national 
quarantine should it be necessary. 


The Stafford Act was developed to address natural disasters or those with physical infrastructure damage. 

As described in the “SNS” Special Topic, it is an exercise artificiality that the push packages were deployed at 
all. In a real event, the SNS reaction to requests for SNS would have been to send the Vendor Managed Inventory, 
since Pneumonic Plague was already identified. Nevertheless, during the FSE top officials in Illinois had to make 
decisions as if they had a limited supply of prophylaxis. 


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e. Management of economic impacts of increased security measures. 

The FSE did not play out long enough for players to have to manage the economic implications 
of increased security measures, with the exception of potential impacts relating to the various 
alert elevations to Red. There are numerous instances in which agencies at all levels actively 
considered such impacts. The Information Analysis and Infrastructure Protection Directorate 
within DHS examined economic impacts of the nationwide alerts on May 14, 2003. Concerns 
related to this were a dominant theme in the Alerts and Alerting session at the AAC. 

These issues were front and center at the post-FSE tabletop exercise held in the Washington 
venue on May 15, 2003, and also at the LSG (see LSG AAR) held in December 2002''*. In the 
tabletop, participants recommended the involvement of the private .sector to lend insights into 
this critical aspect of recovery and restoration. The Director for Economic Consequence 
Management at the Homeland Security Council was in attendance and stated that a Working 
Group would be established to initiate economic analysis using the Department of Commerce to 
evaluate the magnitude of the incident, and later develop two-week and two-month assessments 
to better understand the impacts. The Working Group would identic what federal resources 
might be available, but would work through local and State officials and the private sector to 
develop a local economic recovery plan and to make recommendations to the White House on 
needed resources. 

During the LSG, participants in the economics group cited the need to conduct micro- and 
macro- economic disruption analysis; develop a long-term recovery plan; and catalogue available 
federal support across agencies. The Canadian delegation at the game predicted an increased 
focus on protecting national critical infrastructure and expectations that the private sector would 
start spending more on security, rather than waiting for government help. During T2, the private 
sector was minimally represented. Numerous participants suggested expansion of private sector 
participation in future TOPOFFs and the continuance of events such as the LSG to examine 
longer-term issues such as this. 

f. Understanding the extent to which condition Red changes every aspect of decision- 
making 

This issue was difficult to assess during T2, partially because many of the broad-reaching 
increased security measures one might expect under Threat Condition Red were already 
implemented (or in the process of being implemented) by the two participating venues as direct 
protective action responses to the specific attacks they were facing. Another reason this is 
difficult to assess is. as was discussed under the Special Topic section on alerts and alerting, 
there was widespread uncertainty on the part of most agencies as to what actions they should be 
taking in response to Threat Condition Red. This topic, for this reason alone if nothing else, 
merits continued attention and refinement by agencies at all levels. Future TOPOFF exercises 
might consider inviting States or cities that are not directly affected to participate in the FSE to 
gauge this and other national issues. 

g. Handling/understanding long-term restoration impacts 

Long-term restoration impacts were not played during T2 due to the duration of the exercise. 
They were addressed in the LSG where participants from FSL and international agencies, as well 


The LSG examined longer-term impacts in the aftermath of terrorist WMD attacks. 


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as the private and non-profit sectors spent three days actively discussing long-term restoration 
challenges in the aftermath of terrorist WMD attacks in three post-attack “moves:” Move I, 30 
days out; Move II, 30 days through 6 months out; and Move 111, 6 months out and beyond. 

In Move II of the LSG, the issues centered primarily on the areas of decision-making and public 
information as participants cited ripple effects of security measures on the economy and 
international communities, the lack of a tax base to support needed revenue streams, continued 
issues in maintaining public confidence, managing economic impacts, managing calls for 
bureaucratic reorganizations, and managing growing accountability/liability issues with 
government actions. In Move III, participants were very cognizant of the fundamental shift in 
the national psyche that would have occurred by a campaign of terrorism stacks, and which 
would affect every sector, particularly the economic sector. They cited the tremendous drain on 
personnel and budgets in many localities, but specifically those directly affected by the RDD and 
bioterrorism attacks. They raised the issue of the continued and ever-^esent threat of future 
attacks, and how to improve prevention. Finally, they cited the numerous economic measures 
that would need to be taken by corporations and citizens to supplement the economy. Long-term 
remediation of a radiological incident site was not fully addressed during T2, not even during the 
LSG. In reality, it would receive heavy state, local, congressional, and media attention and 
would be one of the most critical aspects of response. The responsibility under existing plans for 
carrying out clean up activities is not clear under existing policies and should be examined in 
future exercises. Further the FSE did not play out long enough to fully exercise the public health 
implications of a bioterrorism attack. Participants unanimously cited the value of exercises that 
force them to confront and explore long-term restoration issues and impacts. The building-block 
structure of the TOPOFF Exercise Series lends itself to examining these issues. 

4. Conclusions 

Two groundbreaking decisions were addressed during the FSE that have not yet occurred in the 
real world: 

• Elevations to red by City, County and Federal authorities (DHS); and 

• Request for and issuance of a Presidential Declaration of Emergency for a bioterrorism 
disaster. 

Decision-makers at all levels struggled with these and other difficult emergency public policy 
decisions, demonstrating that foreknowledge of the scenario by some participants in no way led 
to foregone conclusions. 

The ability of decision-makers to obtain or discern reliable, validated, timely information, and to 
translate complex technical data into information that informs policy decisions, emerged as a 
primary challenge that underpins this entire core area. Quality decision-making does not mean 
that the decisions do not change or are permanent. Quality decisions are based upon the best 
information available at the time — information that sound processes help to ensure is valid. As 
the information-baseline evolves and decisions must be re-examined, there is a solid basis for the 
new decisions that emerge. Quality decision-making is marked by a thorough understanding and 
assessment of the tradeoffs at stake, which is only possible by having the correct expertise and 
decision authorities at the table. 


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The international scope of T2 and active participation of the Canadian Government expanded the 
scope of decisions faced by domestic top officials in the exercise. It represented a significant 
new element of the TOPOFF exercise design and participants have stated that it should be 
expanded upon in the future. The international implications of domestic decisions made during 
T2 are addressed with the T2 AARs produced by DOS and the Canadian Government. 

While the economic impacts of terrorist attacks and resulting security measures and long-term 
restoration and recovery issues were not exercised during the FSE, participants throughout the 
exercise expressed continued interest in exploring these issues. Future TOPOFFs should expand 
on the concept of the LSG, which addressed long-term issues such as these in-depth. Finally, 
public response was not aggressively played during T2 and may be another element worthy of 
consideration to further challenge decision-makers in through branches andpwjuels in future 
exercises. \ 



160 



T2AAR 


T2 


B. Emergency Public Information 


1. Introduction 

By definition, the term emergency public 
in/urmafion reflects an understanding that 
public information during an emergency 
might differ from business-as-usual public 
information. Further, the task of those 
responsible for public affairs might vary 
according to the type of emergency — natural 
disaster or terrorist attack. For these rea.son.s, 
those responsible for public information may 
find that despite the fact that they do their job 
every day, it becomes different, and very possibly more important, during a set of events like 
those that were simulated during T2. 

The 9/11 attacks and the Maryland/Washington D.C./Virginia sniper attacks of 2002 
demonstrated another unique aspect of terrorism regardless of scale: The acts may have been 
local in nature, but they were national in impact. These challenges caused emergency public 
information to emerge as a top issue in TOPOFF 20(X) and in T2. T2 provided a context in 
which emergency public information strategies could be tested, examined, and refined under the 
challenge of dealing with two different, simultaneous attacLs (with more potentially in motion). 

The T2 design did not include an aggre.ssive news-gathering function with multiple reporters 
calling the offices of top officials; it did not include substantia! injects of simulated public 
responses to information: and it did not involve print or radio media outlets. Also, many of the 
most likely spokespeople in real emergencies — top officials — were not able to play at a level to 
truly simulate round-the-clock, real-wi>rld public information involvement. Special mention 
should be made though of those federal officials such as the Secretaries of DHS and HHS, as 
well as local officials such as the Mayor of the City of Seattle, who played extensively. 
However, these design elements, while potential considerations for future exercises, are not 
necessary to explore and exercise emergency public information issues. During T2, public 
information officers (PIOs) participated; media was simulated in some cases through the use of 
the Virtual News Network (VNN); and press releases were developed that, had this been a real- 
world event, would have been broadcast. This area of analysis examines those sources, as well 
as available broadcasts of real-time interviews by phone or in person through VNN, to 
understand what messages were (or would have been) delivered to the public, by whom and 
when. 

2. Background 

The first emergency public information challenges during the Full-Scale Exercise (FSE) arose in 
the wake of the unexplained explosion around noon on May 12, 2003. in the South of Downtown 
district of Seattle. The Mayor of Seattle, the Fire Chief, the Police Chief, and the Public Health 
Seattle/King County (PHSKC) Director held their first press conference 60 minutes after the 
explosion. The Mayor confirmed the presence of radiation in the explosion area and the PHSKC 
Director issued guidance to shelter-in-place in the central business district and other areas in the 



161 


T2AAR 


T2 


vicinity. They instructed the public who may have been exposed to radiation to remove clothes, 
shower/bathe, lather, and not to consume food or water in the affected area. 

Thirty minutes later a Seattle spokesperson announced the activation of the Seattle Emergency 
Operations Center (EOC). The public was urged to avoid areas within one mile of two cross 
streets in the affected area. Although it was not broadcast on VNN, Washington State released 
an announcement in this same timeframe noting the activation of the State EOC, outlining the 
State’s role to monitor the situation, and reminding the public not to call 911 except for life- 
threatening emergencies. 

The Department of Homeland Security (DHS) did not make a public statement about the 
explosion until nearly eight hours after the attack when DHS Secretary Ridge announced the 
elevation of the Homeland Security Advisory System Threat Condition to Red for seven cities. 
This may have been artificiality, but it is noteworthy. 

In Illinois, public information challenges aro.se when the first patients began reporting to area 
hospitals with mysterious flu-like symptoms. The Mayor of Chicago addre.ssed the city in the 
aftermath of the radiological dispersal device (RDD) explosion and instructed the city that the 
government was on higher alert. However, the bioterrorism attack had already occurred with 
releases in three locations on May 12, 20()3. The Governor was the first to address the state and 
the nation regarding the outbreak of plague on May 13, 2003. 

During the T2 building-block activities leading up to the FSE, but particularly in the seminar on 
emergency public information, participants identified numerous issues regarding public 
information. Many of these played out during the FSE. Examples include speaking with one 
voice, the need for more coordination on public health messages at all levels of government, 
finding the right contact in an organization, and the need for cross-border communications and 
coordination. 

Participants in the building-block activities also cited concerns with public information related to 
the HSAS threat level. They mentioned the need to better understand what type of threat 
information to give to the public, the need to provide protective action guidance with threat 
levels, the need to balance threat fatigue with heightened anxiety, and the need to effectively 
handle the first hours of an attack before a Joint Information Center (JIC) can be established. 
Other concerns included managing rumors, the importance of clear and consistent messages from 
multiple spokespersons, the need to provide credible explanations for restrictive public policy 
decisions such as quarantines, and the need for accurate information to support decision-makers. 

Table 12 depicts the challenges and good practices relevant to Emergency Public Information 
that arose in the seminars, as well as the instances that show how these issues played out during 
the FSE. Instances are occurrences experienced by participants during the FSE that indicate 
challenges or good practices associated with particular issues. In the table, a (-) is used to 
indicate challenge, and a (-(-) indicates a good practice. A ( ) is used to indicate a neutral 
observation in the FSE — one that is neither a good practice nor an issue. Good practices are 
those practices that players felt were effective, or that the data indicate worked well;*^^ these 
practices could potentially be explored further or promulgated on a broader scale. Challenges 

References in the table are based on specific references in the data. Just because something is not specified as a 
good practice does not mean it did not go well in participants’ opinions or did not happen. 


162 



T2AAR 


T2 


are examples of the T2 response that were difficult for the responder community and which had 
significant impact on decision-makers. Challenges do not imply wrong actions or incorrect 
responses by any organization or the community at large — this After Action Report (AAR) and 
the analysis as a whole did not focus on evaluating right and wrong actions. Challenges require 
the continued attention of the national response community to facilitate smoother responses in 
the future. 

Table 12. Emergency Public Information Issues during T2 




ISSLC.S 

Sf:minaks/LSG 

FSE I.\STANCRS 

Good practicf-s and chai-I.f.nges 

Emergency Public 
Information 

Radiological Dispersal 
Device 

Bioierrorism 

Direction <S Control 

Large-Scale Game 
Consequences 

a. Managing rumors, conflicts, 
and misinformation. 

✓ 

✓ 

■/ 

1 

✓ 

✓ 

(■t-) State'ai^lo^ agencies in Washington and 
Illinois c'oniBcied the Virtual News Network to 
dispel rumor^ 

(+) City of Seattle appeared to give hourly press 

ig^^Knces. 

b, “Speaking with one voice" — 
one me.ssage/multiple 
spoke.spersons. 

✓ 

✓ 

1 

✓ 

✓ 

, (+) The Principle Federal Officials in Washington 
and Illinois emphasized the need for one message, 
and consistency with State and locals. 

(+) Ciiy/Couniy/Staic joint press conferences were 
held in Illinois and Wa.shington. 

(+) Regional Joint Information Center (JIC) in 
Washington and “joint" releases in Illinois. 

(-) Multiple phone numbers given for information 
in both venues. 

(-) Conflicting messages given by different officials 
and agencies. 

(-) Little coordination between Federal agencies 
and State/local JICs. 

(-) Inconsistent messages from City/County on 
safety of perimeter zone and foixl/water safety in 
Washington. 

(-) Cily/County and Federal messages had different 
themes about the radiological dispersal device. 

(+)Agencies in both Washington and Illinois used 
information provided by the Centers for Disease 
Control and Prevention’s (CDC) Health Alert 
Network (HAN) and other CDC sources. 

c. Maintaining spokesf>erson 
credibility. 

✓ 

■ 

✓ 

✓ 

■ 

Not exercised. 


163 


















T2AAR 


T2 


Issues 

Seminaks/LSG 

FSE Instances 

Goon practices and challenges 

Emergency Public 
liifornuilioii 

Radiological Dispersal 
Device 

Bioierrorism 

Direction & Control 

Large-Scale Game 
Consetjuences 

d. Providing consistent Protective 
Action Guidance (PAG) for threat 
elevations and explanations of 
rationale for both PAGs and threat 
elevations- 

✓ 

✓ 

1 


V' 

(+) Rationale for sheUer-in-^hh;e inessages^^k 
appeared to make sense, bu^late^rconsistencie^' 
may have complicated Ihinglt 

(+) Rationale for day'**" addaaey in Illinois 
made sense b^d upoMteeaid'gansmission 
information. ^ 

\ V » 

(+)^onsi9eQi mtMages in Vl&shington regarding 
the «teltei4B-plac?^ttets. ' 

(+) Cbiengo \l|yor/Offtce Emergency Management 
explained'peote^ve actions for Red. and why more 
info could'Bnl be tdiared (security). 

(-) Very little guidance was given to the public in 
both national elevations to Red. 

|M|LiKte explanation for why entire country was 
cRvated to Red. 

(-) Radiation guidance to public in WA was to 
shower, bag clothes, stay inside; but health workers 
were told to wear masks. 

(-) Plague guidance to public in Illinois was to stay 
inside and avoid those with symptoms, but health 
workers were told to wear masks. 

(•) Inconsistent treatment guidance for plague 
transmis.sion: Illinois Department of Public Health 
(IDPH): Surgical masks: the CDC: Masks may not 
be necessary; the Department of Homeland 

Security (DHS): N-95 masks, goggles, glasses for 
healthcare woricers. 

(-) Inconsistent messages on transmissibility of 
Pneumonic Plague (Ridge; "not contagious person 
to person"; CDC: “extremely transmissible," CDC 
and IDPH: six feel; Canada; three feet- 

e. Handling eaily post-attack 
information when information is 
limited (pre-JlC). 

1 

1 

1 

✓ 

1 

(+) Top Officials at all levels appeared forthright 
about what wasn't known. 

(-)Some statements were made prematurely and 
were changed later. 


130 

As used during T2. the phrase "snow-day" was to indicate that the public was to slay al home as if they were impacted by a major snow 
storm. 


164 











T2AAR 


T2 


Issues 

Seminaks/LSG 

FSE Instances 

Goon practices and challenges 

Emergency Public 
liifornuilioii 

Radiological Dispersal 
Device 

Bioierrorism 

Direction & Control 

Large-Scale Game 
Consetjuences 







(-) Shelter-in-place zone had to be expanded. 

f. Having pre-ccxirdinaled 
information packages. 

✓ 



V 

✓ 

(-) Some agencies (c.g., CDC. CSQrof Seattle) h#l 
pre-packaged material to disseminate or upload 
onto their wehtffte.'iiuttbcse packages were not 
coordinated v«fah other nicies. Agencies 
uckiunvledgedM Hoiwasfutlbat this would have 
been helf^l 

(+/-VpubUe Affairs Rtal'f in the Illinois Slate EOC 
Office of Huiaaa Services worked aggressively to 
anticipate questions the public would ask to 
coordinate snswets. However, this coordination 
occurred after plague had broken out. 

g. Ensuring accuracy. 

✓ 

1 

1 

V 

1 

{ ) Attempts were made to ensure accuracy of 
information but coordination was extremely 
difBcuIl. 

(+) Seallle/King County coordinated with City of 
Chicago for information sharing. 

h. Coordinating cross-bttrder 
messages. 

✓ 

■ 

■ 

✓ 

■ 

Not played enough to assess. 

i. Handling intense media 
pressure. | 

■ 

■ 

■ 

✓ 

✓ 

NA: Not played. 

j. Balancing public information 
needs with national security needs. 

■ 

✓ 

■ 

■ 

■ 

Not sufHciently played to assess. 

k. Mininiizirtf unintended 
consequ9*ces;-. (i.e., the worried- 
well). 


✓ 




(-) Washington information was not sufficiently 
clear to avoid potential floods of worried well — 
especially since radiation is invisible. 

(+) Clear messages in Illinois on potential infected: 

At release site or person-to-pwrson contact with 
symptomatic people. 

(-) Attempts to require proof of presence at release 
sites (Chicago/DuPage County). 

1. NEW: Unclear language. 

1 

1 

1 

1 

1 

(-) Different technical terms used by spokespeople 
with no explanation. 

(-) Confirmation of diagnosis of non-specific 
"plague" by top officials. 

(-) Unclear distinction between essential/non- 
essential workers. 


165 

























T2AAR 


T2 


a. Managing rumors, conflicts, and misinformation 

The artificiality of VNN. coupled with both 
the standard and large-scale information 
coordination issues experienced during any 
crisis, combined to create conditions where 
participants were able to exercise this 
challenge during T2 play. Rumors abounded 
during the FSE as they would in any real life 
crisis, and determining which rumors were 
true during the FSE proved no less 
challenging in many cases. For reasons that 
can be attributed to both the artificiality of 
VNN and information coordination issues, 

VNN carried information that was not always 
accurate. For example, on May 14, 2003, at 
0945 Eastern Standard Time, the Department 
of Health and Human Services (HHS) was 
concerned that VNN was running numbers on 
plague casualties that were inconsistent with 
those given by their Secretary’s Emergency 
Response Team (SERT). HHS public affairs 
contacted VNN to correct this. Coordination 
occurred between the State health department 
and Interagency JIC, and the City of Chicago 
held a press conference to attempt to correct 
this inconsistency. In the end, the explanation 
for the erroneous numbers was an artificiality: 

VNN stated that it was instructed to only 
report numbers that the Master Control Cell 
(MCC) gave them. But the exercise in rumor control was a valuable one. In Illinois, the 
Chicago Office of Emergency Management (OEM) contacted VNN to correct the address of one 
of the distribution sites that had been broadcast incorrectly. 

In contrast, another rumor that was broadcast on VNN proved to be due to player actions — the 
rumor that Prussian Blue was being delivered at the request of the state. In fact, the state did not 
request Prussian Blue; the origin of this rumor was DHS. the Federal Drug Administration 
(FDA), and Federal agencies that were arranging for the delivery of this treatment through the 
Strategic National Stockpile (SNS). Participants at the Interagency JIC and the State EOC acted 
to dispel this rumor by contacting VNN, as well as Federal agencies in Washington, D.C. 

The Washington State EOC called VNN to correct erroneous reporting that hospitals were 
overwhelmed. Seattle and King County attempted to dispel rumors on VNN regarding Marshal 
Law being considered (it was not). Finally, some organizations held hourly press conferences 
that would have been effective in helping to maintain a constant stream of “official” messages to 
the public. One agency, the Environmental Protection Agency, even had a rumor board to track 
down and validate rumors. 



“Top Ten” Rumors in FSE Play* 

1. 

There was a secondary explosion. 

2. 

Air samples detected Strontium in 
the RDD. 

3. 

There are staff absences in 

Chicago hospitals. 

4. 

The Chicago aiiport is closed. 

5. 

18 Chicago hospitals are on virtual 
closure. 

6. 

T2 exercise temporarily stopped in 
Chicago area on 5/14. 

7. 

Prussian blue was delivered to 

Seattle. 

8. 

The threat level was elevated for 
the nation at 1 600 hours EDT on 

May 12. 

9. 

Prussian blue is a protective paint. 

10. 

The RDD explosion occurred at 
noon on May 12. 

*Bolded rumors were true and others were false. | 


166 




T2AAR 


T2 


b. Speaking with one voice — one message/niultiple spokespersons 

Not surprisingly, speaking with one voice proved to be one of the greatest emergency public 
information challenges experienced by participants. Table 13 depicts the many public 
information voices of various organizations over the course of the FSE.'^' 

Table 13. Active Voices in Public Information during T2 FSE 


ORGAMZ.4TION 

5/l2A»3 

s/im3 

5/14/03 

S/15/03 

Washington Venue 

Washingmn State Emergency 
Operaiiotts Center ( EOCl 

■ 

1 


1 

Seattle HOC 

■ 

■ 


. 

Seattle- King County Kegiunai 
Joint Inrtirmalion Center |J)C) 

V 

1 

♦ \ ✓ 


King County JIC 

■ 

■ 


• ' 

Washington Dopannient of 
Public Health (DPHI 

■ 


— t 


Washington Stale Ferry 

■ 

, 



Seattle Police 

■ 

. 

- 


Harborview Mcilical Center 

■ 




Federal Bureau of 

Inve.Htigation (FBI) TIC 


■B 



Federal/Interagency Venue 




Meadquaners Department of 
Homeland Security (DHSI 


■ 

■ 

■ 

DHS/I'cdcral Emergency 
Management Agaacy ^EMAl 

• 


■ 

■ 

tkaldHarler^ IJcpanmeni :l<t 
'Tleafi(i«d Human Services 
IHHSI 


■ 

1 

■ 

HHS/Ceniers femseu.se 
Control and Prevention (CDC) 




1 

HHS/Federal Drug 
Administration (FDA) 


■ 

■ 

■ 


'' This table presents representative set of organizations that prepared or delivered messages for the public ba.scd 
upon press relea.se.s submitted at the close of the FSE and the VNN interview record. It does not necessarily reflect 
all organizations preparing such messages nor necessarily account for every day the depicted organizations were 
preparing such messages. 


167 


T2AAR 


T2 


OlUiANlZA'IIOS 

5/I2/U3 

5/13/D3 

5/14/03 

5/15/03 

FBI 




■ 

Departmenl of Slate 



■ 


FDA 


■ 



Deparuiient of Labor/ 
Occupalicmal Safely and 

Heullh Administration 



■ 


State of Illinois Venue 



t \ 

DHS-Chicago 



■ 

i 

FBI-Chioago 





Office of ihc Govenior 


■ 

1 

\\ m 

Illinois Emergency 

Management Agency 


■ 


^ ■ 

Illinois Depiinmenl of Public 
Health 



'V' N 

\ 

■ 

Illinois Slate Police 



■ ' 

■ 

Regional JIC 


'I .. 

^ 1 

■ 

City of Chicugii/Office of 
Emergency Management 

■ 

■ 

1 


Chicagn Department of Public 
Hcalih 

4 

■| ^ 

1 

■ 

Ctiok County Depactmenl of 
Public Health 

1 

1 

1 


Kane County Oepanmeni of 
Public Health 

a 

r' 

1 


DuPage Counw'BefM^enl 
ofPublicHet# 

t’* 

■ 

1 

■ 

* . I' 

UikoPounly Depanmenlipf 
Pjltfc^Healih ^ 

' 


■ 



While bO^h venues implemented regional JIC concepts, the organizations shown in the table 
produced at' least one independent press release. As many participants pointed out in the 
seminars, multiple spokespersons are to be expected in an event of the magnitude any weapons 
of mass destruction (WMD) attack would produce, and that is not necessarily problematic. In an 
emergency of the scale and psychological impact of a terrorist WMD attack, it is critical that 
government spokespeople speak with one voice and have a consistent message. But having one 
government voice is usually easier said than done and is an issue of coordination as much, or 
more, than one of politics. 


168 


T2AAR 


T2 


During T2 there were instances of good coordination between Federal, State, and local 
government organizations in both the radiological and bioterrorism public information 
campaigns. In Washington, leaders were consistent with the public guidance to shelter-in-place 
following the radiological attack. They were generally consistent with protective action 
guidance to remove and bag clothes, take a warm shower, lather, and remain indoors. 
Jurisdictions were consistent with messages regarding transportation closures. In Illinois, leaders 
were consistent with messages telling people to seek emergency medical care immediately if 
they believed they were exposed to plague or were symptomatic. The leaders in Illinois were 
also consistent with transportation closure messages. Leaders at all levels attempted to reassure 
the public that the communities would get through this difficult and frightening time, and to 
remain calm. 

There are numerous instances of organizations coordinating within and between JICs and 
reaching out from local to State to Federal levels. In both venues, the Mnciple Federal Official 
(PFO) from DHS emphasized and worked for a consistent federal message that was consistent 
with the State and local messages. In some cases, joint press conferences were held with 
representatives from the Washington State, the City of Seattle, King County, the JIC, and others. 

However, there were a number of occasions where different voices were providing different 
messages — a fact that likely would have caused confusion. Tables 14 and 15 highlight messages 
that were conveyed via press releases from various organizations in Washington and Illinois. 
The messages were in five areas: relative danger, where to obtain information, protective action 
guidance, guidance regarding the red threat condition, and how to know if you were 
contaminated. 

In Washington, the public was given five different phone numbers and at least two websites at 
various times for information relating to the RDD attack by organizations including the 
American Red Cross, the City of Seattle, Federal Emergency Management Agency (FEMA), 
King County, and Washington State. While each number may have served a distinct purpose, it 
was difficult to know for sure what number to call for what purpose, and they were not released 
as a coordinated "joint” set 

Finally, the Regional Disaster Plan signed by numerous agencies in the City of Seattle and King 
County designates the City of Seattle as the lead agency for a regional JIC. The City established 
a JIC at its EOC to which King County sent a representative. King County however, also 
established at least one JIC and proceeded to release messages independent of the City of Seattle 
that were not always coordinated. This contributed to inconsistent messages to the public. 


169 



T2AAR 


T2 


Table 14. Public Messages in the State of Washington 


Mentc* 

Categories 

Rtgiaul 

lie 

Ci(> of 
.Seattle 

Kii«ctMwtric 

WA State 

FBIJIC 

FEMA 

DBS 

CDC" 

FDA 

American 

Red 

Cross 

RtlaUve 

Danger'" 

Lov. 

Medium 

l-0» 

Medium 

NA 

NA 

llj|b 

NA 

NA 


Where (ci get 
infonmiUoR 

Gewtal 

infktmwiion 

866- 

4CRIS1S 

Pencttl 

infi>rmnrinn 

OneRil 

ttiformodon: 

800-J5S 

HELP 

Citwr*! tnformniioh 

S66-ICK1SIS 

Crrsii Chnic; 

106461-3200 

time County 

Kmnliivprs* 

206-:W5-860l) 

R«mH 

y 

' 

877-940- 
4700 (Upyj 

V 

/ ■ “1 

1 

1 X 

NA 

NA 

'\ 

* 

NA 

V 

e' 

\ 

866-GET- 

INFO 

2U6-32.t- 

2345 

WWW .rede 
^jFtw.iirg 

206-2<»-8H)0 

WJO-(W.S-RtMD 

Sehmlt. 

tWPVAnww.schoQlrw 

onoto 

wwv».oovlink.orQ 

■SouiKlTtanyii 

XKK-8in-6368 

www.BOun<llransrt.oi 

a 

Water Tbm 

. 

lnt.mnmK.n 

(2O6i.SJ.l-3tKI0 ■ 

8S8-808-7IJ77 - 



Prutartive 

Arlion 

Ouitiance 

.Sbelicr-ui- 

placc 

Shower 

Hjg L'Uilhu 

Don’t 

consume 

t'lnid/ water 

Shdler-ui- 

placf 

Shower 

Bug LkHlies 

Don't 

coAMunic 

tiaul/ walsr 

Sbcller-ui-ptace 

t 

Shnwft • 

np<l/wal4 

^*v 

Shower 

.'Sig clothu 

Don't 

cunsume 

food! wuicr 

;NA 

NA 

NA 

PrusMui 

Blue 

Pniyviun 

Blue 

m-aE7- 

JNFO 

www.rnJc 

mss.urg 

CiBkhuKrun 
L'linrilllun Red 


• 

1 

1 

\ 




Av<nd 

public 

^atberuig^ 

lAin'l go 10 

whool/ 

church. 



866-GET- 

INFO 

WWW .redo 
rtisy.org 

How 

if yoii might bv 
coniamiiiAlcd 

•s. 

y 



Y^Udbe 

tbeltenng. 

You'd be sbeliering. 

You'd be 
yhcllering 








'’■ The Centers for Disease Control and E^evention (CDC) provided notional support to the stales via iLs Health Alert 
Network (HAN) and their website. HAN messages do not go directly to the public; rather they are provided to Stale and 
local health departments, other government agencies, and medical organizations to support public information by those 
agencies. The T2 analysts did not have daut from CDC’s website. 

' ’ “Relative danger” refers to the relative overall danger of the RDD explosion that was conveyed to the public through 
various agencies/organizations. 


170 


T2AAR 


T2 


The PHSKC Director stated at 1715 Pacific Daylight Time (PDT) on May 12, 2003, in a press 
conference that there are “little to no long-term health risks from this type of bomb” and that this 
was “not a health emergency.” Twenty minutes earlier, however, a Washington State 
Department of Health (DOH) spokesperson stated in a VNN interview that it was “too soon to 
tell” if there is danger in the downtown area. The type of bomb was not known yet (he had 
previously stated that officials were still trying to determine exact “radiological isotopes") so the 
risks were still unknown. In another example, citizens were at first advised that the water was 
not safe and to only consume water in closed containers. Later that day, the Mayor declared the 
water system was safe. But more messages followed from the PHSKC, again instructing the 
public to only drink water in closed containers and to not let pets drink water from outside. 
Concerns regarding runoff of contaminated water were raised by health and environmental 
agencies, concerns which were later determined not be an issue. 

In addition, Federal agencies such as the FDA appeared to be releasing messages regarding 
Prussian Blue, a radiation treatment for Cesium exposure, that were not coordinated with the 
State and locals officials in Washington. At 1800 PDT on May 12, 2003, the DHS Secretary 
announced on VNN that Department of Energy (DOE) would be delivering unspecified 
medications from national stockpiles. Federal agencies began coordinating the deployment of 
Prussian Blue by around 1300 PDT on May 12, 2(X)3. While its deployment may be automatic 
with DOE as a resource for first responders, neither the local responders nor the State expected 
to need it or use it for the general public. To that extent, public announcements regarding it were 
not synchronized with other messages coming in from State and locals regarding the severity of 
the radiation contamination. The Washington State EOC and the Interagency JIC expressed 
frustration about DHS “making local announcements.” 

During the first six hours of the RDD in Seattle, messages from the City, County, State, and 
Federal spokespeople effectively carried different themes. The city’s messages conveyed a 
disaster of a serious enough scale that a number of emergency public policies had been 
implemented, yet they conveyed the idea that sheltering-in-place was sufficient protection. The 
county’s messages attempted to reassure the public that there was nothing to worry about and 
that there were little to no long-term health risks. Finally. DHS Secretary Ridge reported on 
VNN, six hours into the disaster, that “we’re sending the National Stockpile” conveying a 
potential disaster of a sufficiently large scale that local resources were already overwhelmed. 

In Illinois, messages appeared to be closely coordinated between State and local governments. 
The collar counties and the City of Chicago produced regular joint releases. Independently 
produced press releases by jurisdictions were rare. Overall, this resulted in consistent messages 
regarding instructions to the public and key themes: seek immediate treatment if symptomatic, 
remain calm, and Pneumonic Plague is contagious and serious but highly treatable. They 
released a set of information numbers for the public to use. with one number for each 
jurisdiction. However, there were some inconsistencies among jurisdictions regarding which 
antibiotics would be effective. The City of Chicago stated that Doxycycline was the treatment 
being used, Illinois mentioned the same medication and Ciprofloxacin, and the Centers for 
Disease Control and Prevention (CDC) mentioned four other antibiotics but not Ciprofloxacin or 
Doxycycline, The dominant guidance to the public, however, was to seek emergency treatment 
immediately if individuals believed they were exposed, so these inconsistencies might not have 
had dramatic effects. 


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Table IS. Public Messages in the State of Illinois 


Message 

Categories 

City Of 
Chicago 

Stale nrn. 
IIDPH) 

“JelBl" 

CHy/ 

Couiily 

Omk 

County 

DuFtige 

CouBiy 

Rmm 

County 

Lake 

County 

FBI 

FEMA 

American 

Red Cross 

CDC 

Progoo^ib 

Deadly but 

Lrcuiable 

with 

antibiotics 







NA 

NA 

NA 

Deadly bui 
ireatahle with 
antibiolics 

Where (Cl gei 
infornuiljun 

312-743- 

INFf) 

Animal 

Health: 

217.7X2. 

4M4 

www.Slate.i 

LlJS/iclDtl- 

rtrflnnntt ? 

X66- 

rOPOFR 


888-555- 

CURE 

63(h682- 

7tirxi 

800-555- 

6.337 

847-377- 

XI3II 

877- 

040- 

470 

0 

(tips 

1 

800- 

621- 

FEMA 

8h6.0ET- 

wssnv.re'd^ 
ss.org ^ 

/ 

Proietiive 

Action 

Guidiince 

Anlibioiio: 

Covet mouth 
when 

CDUgh/snceit 

e 

Whosbiuilil 

EU 

AatihiotK-a' 

I.VIdi Only 
ihiue 

eniKueil to 
rvleave «iie 
IpriH'l 
rcquiKill 

(5/IS) 

ExpitfcJ lu 
aiieorclnie 
e(>niw.'l with 

ihovu 

Uimily 
eapoMd to 
nile 

Antibioiio 

DuitycycUBe 

/Cipro 

ViTni shiiiilil 

get 

AntibioOcs: 

lS/13) 

EapoBcd to 

symplnmaiie 

permnn, 

|5/M) 

£ji|ioscil 111 
site or to 
symptomatic 
person 

Who should 

SSI 

Anlihunais- 

l$/l4iOnly 

those u iih 

symptoms 

should seek 

medtcal 

Irealment. 

otherwise 

monitor 

cnmliiion. 

(S/IS) 

Exposed to 

Hite or lu 

symptomalie 

person 

See 'Joint " 

» * 

, « 
r 

tVI2l 

Who 

should 

eelAoti- 

hioocs 

Exposed 
lu sue i« 

to 

sjmpto- 

muilc 

person 

iilll llslil >' 

^ ~ y .flE 

“JoinL’* ^ 
■ 

A. 

\ 

V 

/■ 

NA 

^s\ 

Aj 

NA ' 

■- 

^'C 

Anuhiolics 

Slnpiomsun 

CxVii/iiftifi'/n 

rnnpf.vi'diir 

flsiPIVI- 

ijiiinohni! 

Uisposuhte 

surgical 

musks 

Quid lim e iio 
Cpndiiion Red 

Stay iiulnon '• 

HA 


NA 

NA 

X66-OET- 

INFO 

wwwreJcross 

.org 

Haw ui knim 

if you mighi 
be 

cimtummulni 

/•, 

V 

EJipoaurc to 

otic of 

release siJfMC 

(TemntfS^ 
tapt 2:' 
liiklni'l. 
^wtuefi is 
terminal 3) 

'<lyti of 
^^oniaue 

Eepwiurcio 

one of nticare 
,41 lev 

'{IbnMnal 3i 
im2: 
taW Ini'l. 
whthis 1 

terrainal 5^ ' 

bfoijfr' 

syn^nuiK- 

4 

w 




Exposure 

to ini'I 
terminal 




Exposure to 

release sile/o 
feel ol 

sympioniatic 


USE ONLY 


172 


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Also, there is some evidence of inconsistent guidance to the public as to who should seek 
antibiotic treatment, as there were up to four different messages given to the public: 

• Only those directly exposed to the release sites or to symptomatic persons should seek 
antibiotic treatment; 

• Only those who are symptomatic should seek antibiotic treatment; 

• Only those who were directly exposed to release sites, or in close contact with those who 
were; and 

• Pre-exposed persons considered at high-risk should seek antibiotic treatment (only one 
organization referenced this). 

There was further inconsistency in messages citing the release sites relative to O'Hare 
International Airport, Some organizations cited the affected Terminal as Terminal 2, later 
changing it to Terminal 3 and later calling it the International Terminal (which is Terminal 5). 
At least one organization referred to the International Terminal as Terminal 3. At one point 
controllers advised at least one organization to use Terminal 2. There was also inconsistency in 
the guidance as to what information people should bring with them to the SNS dispensing sites. 
Only the City of Chicago and DuPage County appeared to publish such guidance, advising 
people to come prepared with personal and family identification, and information on drug 
allergies, pregnancy status, and use of contraceptive (City of Chicago only), weight and age of 
children, whether women are breastfeeding (City of Chicago only), and current medications and 
general health status (DuPage County only). One would expect to see this comprehensive 
checklist widely and consistently disseminated. 

One message that did not appear to come out .strongly or consistently was that of the potential 
need for surgical masks, Medical community communications reflect the critical importance of 
N-95 masks'^"^ in reducing the transmission of plague, even specifying that other commercially 
available masks would not be effective. However, masks were rarely mentioned in the press 
releases, and the specific N-95 mask was not mentioned at all. Medical communications also 
reflected concern that there might be a shortage of this type of mask due to the recent Severe 
Acute Respiratory Syndrome (SARS) outbreak, but this did not appear to be addressed in the 
media. In DuPage County, the HOC eventually arranged for a large order of N-95 masks for 
county hospitals. 

The PFOs in both venues observed the lack of Federal agency coordination of messages with 
State and local governments when they arrived, and acted to improve this. The PFO in 
Washington noted ctMicem about “unilateral messages from D.C.” and that no messages had 
come to the JIC despite critical decisions such as the seven-city elevation to Red, road/airport 
closures, and the restriction of border crossings from U.S. Customs. The exercise did not play 
out long enough in either venue to see how the PFO affect this information flow, but the PFO 
role has the potential to strengthen and streamline the flow of key information between the State 
and local governments and Federal agencies during a disaster. 


N-95 masks are fitted surgical masks that provide protection again.st particulate inhalation of contagious 
biological agents. 


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c. Maintaining spokesperson credibility 

Mr. Frank Sesno, former Washington Bureau Chief for CNN, alerted participants during the 
Direction and Control Seminar to be aware that the media will “follow you down your own dead 
ends” and report it. Fortunately, participants did not have to contend with this reality during FSE 
play since there was no active mock-media. For this reason, there was not sufficient data for this 
area to be addressed. 

d. Providing consistent Protective Action Guidance and threat elevation guidance 

Determining how much information to relea.se regarding the rationale for threat elevations is a 
particularly challenging for decision-makers. Balancing the public’s need to know and 
understand certain information to ensure the overall protective posture is indeed elevated, can 
risk compromising national security. At the After Action Conference, participants voiced strong 
concerns regarding the lack of specific intelligence from official Federal to State and local 
channels regarding the nature of the threats or the rationale for threat elevations. In many cases 
specific information may not be known, but sufficient general intelligence exists to merit an 
increase in the nation’s threat posture. In other cases, classification requirements limit 
information that can be transmitted from the intelligence community to State and local 
governments. DHS is currently examining this issue. 

During T2, little public information was given to explain the rationale for the threat elevations to 
Red. In fact, public announcements regarding the threat elevations were fairly confusing (See 
the “Alerts and Alerting” Special Topic), ofen leaving even government officials uncertain 
about the alert status of their jurisdictions. 

The rationale for the regional Seattle-King County elevation to Red was probably self-evident 
because terrorism was formally suspected by the time of the announcement. In the seven-city 
elevation. DHS Secretary Ridge explained the decision as an action to take additional 
preventative action, based upon both the RDD attack and intelligence that suggested the listed 
cities may be at extreme risk. On May 13, 2(X)3, when the DHS Secretary elevated the nation to 
Red, it was in response to the mounting cases of plague in Illinois and Canada. The public was 
advised to avoid public gathering places, such as churches, schools, and work for 48 hours. 
However, there was no mention as to why people in Topeka. Kansas, were at as great of a risk of 
attack as those in perceived high-risk areas such as Chicago or New York City. 

In examining the Protective Action Guidance (PAG) messages that were prepared for public 
release, one issue that emerged was that the recommendations provided to the public were not 
con^jrehensive. Just after 13()0 PDT on May 12, 2003, in a joint news conference held by the 
City of Seattle and King County, the public was advised that food and water in the area or that 
“may have been exposed” should not be consumed. No guidance was given at that time as to 
what food or water sources may have been exposed or how the public could tell. Later it was 
clarified that food or water in sealed containers, or food that was indoors, was safe to consume. 
A news release from the City of Seattle at 1330 PDT on May 12, 2003, advised that “most 
people” will not experience long-term health effects, but it also advised people to “not take in 
additional radiation.” It did not clarify who might be at risk for such effects or what it meant to 
“take in radiation,” which could appear to imply ingestion or inhalation. It advised people to 
follow the directions of officials who might decide to evacuate people from the immediate area, 
arrange medical treatment for those injured by the blast, and decontaminate those who were 


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contaminated, but it did not specify how one would know if they were contaminated. In fact, 
other messages stated that exposed people (even at the site) would not necessarily feel sick and 
noted that radiation cannot be seen. This could have led to an increase in the numbers of worried 
well and undermined the credibility of the spokespeople trying to reassure the public. 

The news that evacuations were potentially being considered could have been problematic at a 
time when people were also being advised to shelter-in-place without the additional clarification 
that evacuations were intended as a safe and structured means to move those sheltering-in-place. 
Also, initial messages instructed the public not to call 911 except to report life-threatening 
emergencies; however, an alternate number was not offered until almost 90 minutes after the 
blast. Similarly, the public was instructed at first to shelter-in-place, take a warm shower, and 
bag potentially contaminated clothes. Ninety minutes after the first message, they were 
instructed to close windows and turn off ventilation systems, and bring pets inside and bathe 
them. 

In Illinois, people were advised that Pneumonic Plague was potentially highly contagious 
through the inhalation of respiratory droplets. People could contract the illness if they were in 
close contact, which was defined as within six feet of an infected and symptomatic person. They 
were advised to stay home if possible, though essential workers were instructed to report to 
work. But only one jurisdiction specifically advised people to cover mouths when 
coughing/sneezing, and, during the first day of play, no jurisdictions mentioned wearing masks 
as an additional protective action measure. When the additional protective measure to wear 
masks was mentioned the next day, the commercial surgical masks were recommended, though 
health community e-mails indicated that only the N-95 masks were considered effective. 

e. Handling early post-attack information when information is limited (pre-joint 
Information Center) 

In any disaster, particularly one involving a possible terrorist WMD attack, there is much that is 
unknown in the early hours after the incident, including: 

• Whether the event is indeed a terrorist attack; 

• Whether there will be other attacks: and 

• The extent of the damage — particularly from radiological weapons or bioterrorism. 

In the seminars, participants emphasized the importance of early and visible leadership from top 
officials. In Washington, the Mayor of Seattle was on the news within 60 minutes of blast. He 
confirmed radiation early on and issued shelter-in-place guidance to those in potentially 
contaminated areas. Those outside the defined area were told that they did not need to shelter-in- 
place. A combination of factors, such as confusion among agencies in determining the range and 
types of radiation (see the “Data Coordination” Special Topic), as well as changing 
environmental factors, changed the parameters of the contaminated area over time. This caused 
decision-makers in the Washington venue to enlarge the shelter-in-place and exclusionary zones. 

In Illinois, the Mayor of Chicago addressed the city after the threat condition was raised to Red 
(the address was pre-taped), and the Governor addressed the State the same day that the epidemic 
of plague became evident. However, some key messages were delivered much later. For 
example, the news that plague can be transmitted through symptomatic p>eople was given 24 
hours after the first announcement. The public was not advised until May 15, 2003, about the 


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tiansmissibility of Pneumonic Plague through cats and about prophylaxis options. Also, 
immediate guidance was given instructing people to seek medical treatment if symptomatic, but 
specific antibiotic options were not formally mentioned. 

f. Having pre-courdinated information packages 

The suggestion for pre-coordinatcd. agent-specific information packages was made numerous 
times in the various seminars and the game preceding the FSE. While some agencies appeared 
to have some fact sheets, neither Illinois nor Washington appeared to have a robust set of pre- 
coordinated. agent-specific, off-the-shelf information packages. The City of Seattle did direct 
the public to its website ( www.seattle.gov ). where it later clarified that fact sheets on dirty 
bombs, radiation, self-care in times of crisis, and disaster planning and personal prcparcdnes.s 
were made available; no public official or press release ever referenced these fact sheets or the 
availability of fact sheets in general. Public Affairs staff in the Illinois Stale E(X! Office of 
Human Services worked aggressively to anticipate questions the public would ask and to 
coordinate a set of answers. However, this coordination occurred after the plague had broken 
out. The City of Chicago did produce a fact sheet on Pneumonic Plague that was sent out. Some 
Federal agencies, such as the CDC and the FDA. do maintain fact sheets but it was not clear 
which State or local agencies utilized them. 

g. Ensuring accuracy 

Ensuring complete accuracy of information in the midst of a crisis is extremely difficult. 
Decision-makers are constantly challenged to make decisions based upon imperfect information, 
and information that is changing (See the “Emergency Public Policy and Decision-making” Core 
Aren). This is partly due to the rate at which a crisis unfolds, specifically those involving 
terrorist WMD, and partly due to issues with coordination and communication (See the 
Communications. Coordination, and Connectivity Core Area). However, as participants pointed 
out in the seminars, the importance of having as accurate an information-ba.seline as possible in 
an unfolding event cannot be understated. 

During T2 there were challenges in maintaining accuracy of information. An example is the 
casualty counts at the RDD scene in WA. Casualty counts were mounting; yet a King County 
Public Information Officer, speaking for the regional JIC repealed twice in a May 12. 2(X)3, press 
conference at 1600 PDT that there were “no casualties.” By this lime there were more than sixty 
casualties and two deaths were reported in the EOCs. In Illinois, this challenge was equally 
difficult, as the .size of the plague epidemic was growing daily. Leaders in Illinois had a veiy 
difficult lime confirming accurate information regarding patient counts and fatalities (See the 
“Hospital Play” Special Topics). 

Confinning patient numbers in the unfolding bioterrorism event in Illinois proved to be a 
tremendous challenge for a number of rea,sons. not the least of which was the artificiality of 
VNN having been instructed to use pre-scripted numbers from the MCC. which conflicted with 
the numbers being confirmed by players in the Chicago OEM. While this was an artificiality, the 
resulting challenge for players was probably emblematic of what happens in the real world with 
the media and its influence on perceptions of reality. 

Ensuring accurate information depends upon having structured, well-defined and robust 
information flow strategies, where information is accepted from pre-defmed validated sources. 
Such strategies exist in numerous policies such as the Interim Federal Response Plan, but 



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implementation of them remains a challenge. Regional JIC concepts are a critical element of 
such a strategy. Twenty-first century communications technologies both enable and challenge 
these strategies as they eliminate limits of time, distance, and hierarchical structures. 


h. Coordinating cross-border messages 

There was not sufficient data on the U.S. side to analyze this issue. 


i. Handling intense media pressure 

Because news-gathering and public reaction were not played during the T2 FSE, this is5 
not be analyzed. ^ 

j. Balancing public information needs with national security requirements 
This issue was not played in enough sufficient detail to be analyzed, i 






K 



k. Balancing public information needs with national security neet^ 

Because the intelligence process was notionally played during the J2.FSE?»Uits issue could not 
be analyzed, 

l. Minimizing unintended consequences 

Minimizing unintended consequences is challenging by definition. Thorough coordination and 
clear, comprehensive, and consistent messages certainly help in this area. Because public 
reactions were not heavily played during the FSE, this area is difficult to assess based upon 
empirical data. However, there are some instances worth examining as they could have 
potentially resulted in unintended consequences. 

On May 14, 2003, the Chicago DPH i.ssued a press release announcing its distribution plan for 
antibiotics. It stated that proof of presence at one of the three suspected release sites would be 
required as a condition for receiving prophylaxis to prevent the lines from being too long. This 
seemed strange under the circumstances where a) theoretically other unknown releases could 
have occurred or could have still been occurring at that time — the nation was under Threat 
Condition Red; b) the majority of the infected victims by then were second generation cases who 
were in contact with people at the initial release sites. While this message was not formally 
retracted in the exercise, all Jurisdictions in the Illinois venue had agreed by May 15, 2003, that 
anyone who showed up for treatment would not be turned away. 

In both the RDD attack and the bioterrorism attack, managing the worried-well could have been 
a huge challenge for the public health and medical communities and public information officers. 
Clear and consistent guidance from credible spokespersons would be key to minimizing issues of 
the worried-well. Also, in the State of Washington, the exercise ended before officials were able 
to say with certainty what the potential long-term implications of any, or specific, radiation 
exposure might have been, thus limiting the ability to analyze this issue. But, little-to-no 
guidelines were offered to help people who believed they may have been exposed to radiation 
determine with assurance that they had not been exposed. This could have resulted in a flood of 
people to medical centers wanting to confirm whether they were contaminated. 


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m. Unclear language (new) 

Language is critical in a time of crisis. Simple messages are especially important when seeking 
to maintain calm and invoke specific responses from the public. During T2, the use of technical 
language with little-to-no explanation proved to be a potential challenge for the audience. In 
Washington, terms such as multiple alarm response, instrumentation to protect citizens, 
habitability check, external hazard, and not a health emergency were used by various State and 
local spokespeople on the first day. 

In contrast, the greatest language challenge for officials in the bioterrorism attack was one of 
being too vague. The IL Governor’s initial speech confirmed the diagnosis of the mysterious 
respiratory illness as plague. The DHS Secretary, in his speech to the nation on VNN on May 
13, 2003, opened by confirming that the mysterious illness in Illinois was plague, but did not 
specify the type of plague. Some Americans might have assumed he was referring to Bubonic 
Plague — the “Black Death” of the Middle Ages. In fact the participants at the Large-Scale Game 
assumed just that when the type of plague was not specified. 

3. Conclusions 

Emergency Public Information was a dominant theme in TOPOFF 2000 and emerged as a 
dominant issue during T2. It merited its own seminar, and participants raised concerns and 
identified issues in this area in every other seminar. It is not surprising that it emerged as an 
issue during the T2 FSE — unlike everyday public information, leaders in the midst of a disaster, 
especially one involving WMDs, are thrown into an environment of chaos where time and 
certainty compete, and the public’s attention and demand for information are high. Often the 
public’s safety is dependent on the effective communication and receipt of emergency messages. 
This produces an environment of great pressure on top officials to speak to the public and to 
release information — this may result in releasing information that could change, that has not 
necessarily been thoroughly coordinated, and that may not be consistent with other messages 
being relea.sed at the same time. The messages given to the public by officials are competing 
with a flood of non-official messages as well. Establishing consistent messages across all 
official spokespersons is key to maintaining credibility of official spokespeople and is one of the 
most effective ways to retain the public’s attention regarding messages that may be critical to 
their safety. 

Participants stated that the VNN element of the TOPOFF exercises was extremely valuable in 
simulating the realism of the media element. They have also said that they would like to 
continue to be challenged in the area of emergency public information through elements such as 
a robust news-gathering function and simulated public reactions. Many assumed that VNN was 
playing these functions during T2 when in fact it was not contracted to do so. it was intended 
primarily to lend an environment of realism to T2 — not substitute for information sources. 
Interestingly, however, it is a parallel to the real world in which participants have acknowledged 
that they often rely on network news for information because formal channels are slow or 
nonexistent. The reconstruction of T2 illustrates the information validation issues that are 
multiplied when any media outlet sub.stitutes for official channels of information. 

The dominant issue that emerged from this area in the seminars and during the FSE remains one 
of coordination. Creating mechanisms that can support this coordination, in the midst of the 
chaos, is imperative. Ensuring accuracy of information is extremely difficult, and the 


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information will change. A consistent and comprehensive message that is based upon the best 
information available at the time should be the goal of top officials and their PIO staffs. The 
message should be consistent both within any jurisdiction or organization, and with all official 
public messages. The message should be delivered on a consistent and regular basis; this 
strategy appeared to be effective in the MarylandAVashington D.C.A^irginia sniper incident and 
9/11, and appeared to be effective in T2. These three elements — consistency, 
comprehensiveness, and the best information available at the time — are all required, and should 
be goals of future emergency public information campaigns. 

The ability to achieve these goals in emergency public information depends upon having 
structured, well-defined, and robust information flow strategies, where information is accepted 
from pre-defined, validated sources. Such strategies do not exist currently in the national 
response domain, though regional JIC concepts are a critical element of such a strategy. But 
twenty-first century communications technologies make adhering to this critical strategy difficult 
as they eliminate limits of time, distance, and hierarchical structures. Ensuring accuracy of 
information, or at least as best as possible, depends on a comprehensive system whereby only 
information from identified sources is accepted as valid, regardless of whatever other 
information is received. A shared electronic information system could help to streamline 
information flow, and potentially reduce conflicting information. Ideas were raised in the 
seminars such as a regular news center concept and town hall meetings that may offer value as 
well. 

The TOPOFF Exercise Series provides a unique opportunity for jurisdictions at all levels, to 
exercise, experiment with, and improve upon these critical strategies, T2 provided an 
opportunity for participants to showcase the value of concepts, such as regional JlCs, that could 
be expanded for more compreher &ive c oordination at broader levels and in distributed 
environments (i.e., when people cannonfejphysically co-located). Future TOPOFFs should 
continue to allow participants to experiment'in^.s area and should consider expanding on mock 
media functions and mock public response to further challenge participants. 

\ 




V 


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180 



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C. Communications, Coordination, and Connectivity 


1. Introduction 

Nobody questions the importance of communications, coordination, and connectivity in a 
weapons of mass destruction (WMD) emergency response, and few would question that there are 
challenges that need to be overcome in this important area. These challenges are relevant in the 
everyday activities of Federal, State, and local (FSL) authorities, but take on critical importance 
during an emergency, especially one that involves WMD. While there were good practices 
during the Top Officials (TOPOFF) 2 (T2) Full-Scale Exercise (FSE), communications, 
coordination, and connectivity challenges emerged as dominant, if not the most dominant, 
challenges and pervaded almost every element of the response. For the purposes of this 
discussion, commiinicalions is defined as the exchange of information between agencies and 
jurisdictions, coordination is defined as agencies and jurisdictions woridng together to meet a 
common goal or to solve a common problem, and connectivity is defined as the means by which 
communication and coordination takes place. If communication describes the “what,” 
connectivity describes the “how.” The special topic areas provide extensive detail about many of 
the communications, coordination, and connectivity challenges including how they occurred, 
and, where possible, why they occurred. 

2. Discussion of challenges and good practices 

Table 16 depicts the challenges, and good practices relevant to communications, coordination, 
and connectivity that arose in the seminars, as well as die instances that show how these issues 
played out during the FSE. Instances are occurrences experienced by participants during the 
FSE that indicate challenges or good jMactices associated with particular issues. In the table, a (- 
) is used to indicate challenge, and a (+) indicates a good practice. A ( ) is used to indicate a 
neutral observation in the FSE — one that is neither a good practice nor an issue. Good practices 
are those practices that players felt were effective, or that the data indicate worked well;'^^ these 
practices could potentially be explored further or promulgated on a broader scale. Challenges 
are examples of the T2 response that were difficult for the responder community and which had 
significant impact on decision-makers. Challenges do not imply wrong actions or incorrect 
responses by any organization or the community at large — this After Action Report (AAR) and 
the analysis-'as' a whole did no^focus on evaluating right and wrong actions. Challenges require 
continued attentiwi of the national response community to facilitate smoother responses in the 



References in the table are based on specific references in the data. Just because something is not specified as a 
good practice does not mean it did not go well in participants' opinions or did not happen. 


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Table 16. Communications, Coordination and Connectivity Issues during T2 


ISSl'ES 

Se.»i\aks/LSG 

FSE Instances 

Good practices and chali-en(;es 

Emergency Public 
Infomuilinn 

Radiological 
Dispersal Device 

g 

v! 

1 

s 

Direction <S 
Control 

Large-Scale Game 
Consequences 

a. Communication: 

• Processes are needed for distribution of 
critical information between agencies 
and Jurisdictions and for communication 
of data and lab information to Incident 
Commander, 

• Communication of Slate and local 
Emergency Operations Centers (EOCs) 
with hospitals. 



✓ 

✓ . 

✓ 

(-) Lack of consSSai understandii^ttf . 
formal, validaiedcoi^lBs fw informa^n. 

(-) IiUQffie cases, ’jackM^nnal 
prt^ssel^SanellljQ^ndeKf'dnding of 
tbA) for otif^^iwormalion. 

(-) ^gpisient of terms/unclear 

(-ws^ensome/rcdundani reporting 
for hospitals. 

b. Coordination; 

• Integration of agencies to provide unified 
response is not clear. 

• Coordination across multiple agency and 
jurisdiction EOCs. 

• Lack of integration of private sector and 
non-profit organizations in response 
plans. 

• Cross-border/international coordination 
needed. 


✓ 


✓ 

✓ 

Mulhple agencies 

c^eciing/disseminaiing radiological 
ground data in Washington. 

(+) The Principle Federal Official in both 
venues. 

(+) Video teleconferences (VTC) were an 
effective means of coordination. 

<+) In Washington and Illinois, there 
were several examples of EOCs wttrking 
together to solve a problem (procedures 
for re-opening closed roads In 

Wa.shington. identification of additional 
security personnel in Illinois), 

(+) American Red Cross participated in 
the Federal Joint Operations Center 
Consequence Management Group in 
Washington and at the Interagency level. 

(■•■) In Washington, preliminary 
relationships developed between 
businesses and emergency response 
community. 

(+) In Washington, Canada requested to 
place a liaison in the Region X Regional 
Operations Center (ROC). 

(■!■) The Department of Energy requested 
help from Canada on health radiation. 

(+) In Illinois, numerous examples of 
conference calls between EOCs and 
regional Federal agencies (typically the 
Department of Health and Human 

Services Regional EOC and the Federal 
Emergency Management Agency ROC). 


182 













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Isiri'ES 

SE\nsARS/LSG 

FSE Instances 

Good pkaciices and chali.engf.s 

S - 
€ *1 

|4 

r 

Ii 

*s 

£ 

1 e 

Cl 

§ ^ 
tsi 

^ 3 







(-«-) In the Inierngency, ngiti1|f^>tantples of 
Federal agencies cominunicitmig^vilh 
each other. 

(-) Multiple EOC^ stTBlcIi liaisons 
and can complicate ccxtttluiUion 

(+) Prior to the FSE. Wrhingion 
Di^aomentgf HcaMii (DOl-O. Puhlic 

HcvlLh Scaiilc Kh>g County (PHSKC). 
and EPA developed delaull Proleclive 
^^lofllhudelineifor use in an RDD 

c. NEW; Connectivity. 






Washington, Radiation Monitoring 
A^ssment Center couldn't transmit 
data elmronicallyi forced to used phone, 
faib and courier. 

(-) In Washington. Federal Radiological 
Monitoring and Assessment Center used 
S6k modem lo transmit information and 
courier to deliver maps to Joint 

Operations Center (JOC), 

(-) In Illinois, many hospital fax 
machines were unreliable, and there was 
no guarantee of successful data transfer. 

(-) Hospital data were largely paper- 
based and disparate reporting processes 
were burdensome. 

(-) In Washington, inadequate VTC 
capability at JOC. 


-a. Communication 

To the extent that eifective coordination depends on a common information baseline, communication 
issue? are addressed. The volume of information exchanged by players during the T2 FSE was 
extensive. More than 2.500 e-mails alone were courtesy copied (as requested of participants by the T2 
evaluation team for use in subsequent analysis) to the T2@amti.net address, and this is likely a fraction 
of the total volume of e-mails exchanged. This number does not include information exchanged by fax, 
phone, radio, video teleconference (VTC). in person, or obtained by participants over Websites. In 
response to a disaster, agencies produce multiple levels of information of various types: technical data 
that are assimilated into information from multiple sources, individual logs kept by .staff at most 
Emergency Operations Centers (EOCs), organizational situation reports produced at regular intervals, 
summary briefings, and press releases to name a few. 


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Analysis of T2 communications affords a rare opportunity, albeit a limited one due to time constraints, 
to examine this critical element of national response in an objective and relatively comprehensive 
manner. Such an examination is only possible through the artificiality of an exercise that permits 
collection of the information flow that would be impossible to implement in a real disaster. This 
analysis represents the highest-level assessment of this critical area. Further examination of this area is 
strongly recommended to help the national response community understand the existing information 
system upon which their situational awareness depends, including the key information nodes, along with 
redundancies, gaps, or efficiencies. 

During T2, there were two overarching communication issues: 

• Lack of formal processes/channels (or understanding of them) for official information 
and lack of consistent understanding of formal, validated sources for information: and 

• Use of inconsistent or technical language. 

Lack of formal processes/channels (or understanding of them) for official information 

A prevailing issue that emerged during T2 was the lack formal processes or channels for official 
information. In an environment of instantaneous information access through e-mail, pagers, 
instant messaging, and cell phones, adhering to a structured process for exchanging information 
is difficult. Structured processes may be slower than informal processes; however, they are a far 
more effective way of validating information than numerous informal processes. When 
validated information is critical, it is equally critical that mechanisms exist for exchanging it. 

During T2, this played out in numerous ways. Agencies experienced difficulty in validating the 
status of the alert level for nearly 12 hours due in part to the absence of a consistently understood 
process for official notifications in this arena. As described in “Alerts and Alerting" in the 
Special Topics section, many agencies learned about the Department of Homeland Security 
(DHS) elevations through the Virtual New Network rather than through official channels. This 
led to substantial efforts to confirm and validate this information. 

Some agencies attributed information problems to too many official reporting channels — various 
agencies having their own, independent procedures and redundantly requesting updates from 
agencies. Public health authorities in Illinois required updated resource reporting every three 
hours in the midst of the outbreak. In many cases, different agencies [(e.g., Illinois Department 
of Public Health [IDPHJ, Illinois Operations Headquarters and Notifications Office [lOHNO])] 
requested similar information in various formats from hospitals. These cumbersome reporting 
processes appeared to divert resources from other priorities. 

The Federal Bureau of Investigation (FBI) Strategic Information Operations Center (SIOC) is 
staffed by liaisons from other Federal agencies. They are there to field questions, receive 
information from the FBI to pass back to their agency headquarters, and provide information to 
the FBI from their agency headquarters. However, in many cases during the FSE, agencies 
directly contacted the FBI information control officer for information rather than their own 
liaisons. This was particularly true of DHS. 

T2 provided an unprecedented opportunity for traditional government response agencies to 
interact and work with the public health and medical communities. Hospitals reported that they 
established many positive working relationships with many FSL agencies. However, they 


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reported that numerous calls from a variety of people from the same Federal agencies caused 
some confusion. 

Agencies spent substantial time validating rumors about transportation closures, patient numbers 
in both venues, casualty figures from the radiological dispersal device (RDD) scene, and others 
due in part to a lack of understanding of validated sources. For example, in the Washington 
venue, on-scene responders were repeatedly asked about the number of fatalities. Partly because 
of the “fog” and urgency of a disaster, responders attempted to provide what they knew, rather 
then defer to the Medical Examiner,’’’^ leading to inconsistent estimates of the number of dead. 
In other cases there was a lack of understanding by official sources as to the complete list of 
information consumers. Both contributed in to a “whisper down the line” phenomenon as 
information was passed from primary recipients through secondary channels to others who 
passed it along, unintentionally altering the information along the way as in the childhood game 
“Telephone.” 

Finally, there is some evidence to suggest that although many agencies, including DHS, initiated 
regular reporting intervals, not enough agencies did this. Those that reque.sted “on-demand” 
reports often did not allow staff sufficient time to gather information. For example, a 
Department of Health and Human Services email notes that: 

A request was made by the FBI Consequence Management Group 
Leader to have each agency provide talking points for a report to 
the Principle Federal Official, who will update the President of the 
United States. We had about 10 minutes to pull this information 
together, so I contacted ROC [Regional Operations Center] and 
REOC [Regional Emergency Operations Center]/or assistance. 

While this individual sought out official sources for information, a ten-minute notice for updates 
across all major elements of a disaster response is a recipe for potential information issues. 

Inconsistent use of terms/unclear technical language 

The use of inconsistent language proved to be another communications challenge during the T2 
FSE. In the Washington venue, confusion arose with the interchangeable use by many of the 
term casualties to mean both fatalities and injuries, or both. The “Emergency Public 
Information” discussion in the Core Areas section details some additional issues with the usage 
of language for public information. Some of these same examples were issues in internal agency 
communications. Specifically, the general reference in internal agency communications to the 
plague resulted in at least one instance of a public health person giving advice that applied to 
Bubonic Plague (preparing information to reduce transmission through rodent population) rather 
than Pneumonic Plague. Officials remarked about the critical importance of having technical 
data translated into plain language to support decision-making and risk communications. 

b. Coordination 

In the Illinois venue, the greatest challenge involved the coordination of actions, information, 
and data flow requirements among 64 hospitals, five POD hospitals, and three separate but inter- 
related state-wide organizations (IDPH, lOHNO, Illinois State EOC). In Washington, there were 


In Washington, the Medical Examiner is the formal source for confirming deaths. 


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many agencies collecting radiological ground data to assist in the determination of the extent and 
type of contamination caused by the RDD explosion. Early on, these agencies transmitted their 
data on-demand to numerous other agencies — in many cases by-passing the coordination 
processes and mechanism of the Federal Radiological Monitoring and Assessment Center 
(FRMAC). In some cases, these agencies were measuring slightly different things, though such 
differences were not necessarily understood by the recipients of this information, many of whom 
were not technical specialists. This proved to be problematic later on when these data were used 
by several different agencies to create inconsistent plume and deposition models.'^^ 

At the RDD site in Washington, there were some issues with the apparent lack of a unified 
command structure during the early stage of the response. Although, there were a number of 
briefings attended by the Seattle Police Department (SPD) Incident Commander, the Seattle Fire 
Department (SFD) Incident Commander, the FBI, and the Federal Emergency Management 
Agency (FEMA), there was no mention of a unified command to facilitate coordination efforts 
until 0915 on May 13, 2003.'’* However, even that briefing did not include representatives from 
health or emergency medical services, leaving full coordination nearly impossible.'’'^ A data 
collector commented after the exercise: 

While all disciplines were present, there h’oj no indication that 
they were truly working together. In fact, except for the briefing.^, 
the only interdisciplinary coordination occurred by “chance 
meetings... ” 

An additional coordination problem arose with the DHS National Operations Center and the 
Washington State EOC regarding deployment of the DHS Prepositioned Equipment Package 
(PEP). On the second day of the reE, the Incident Commander requested deployment of the 
PEP. Per the guidelines in the DHS/ODP PEP Briefing Book, a request for deployment of PEP 
from the Washington Governor, was processed through the Washington State EOC. The data 
show that attempts were made to follow established PEP guidelines; however, the guidelines 
were vague and did not provide sufficient detail. For example, the request for deployment must 
come from the Washington Governor, but it was not specified if a verbal request is sufficient or 
if the request should be in writing. The request was eventually routed through the FEMA liaison 
in the Washington State EOC. However, once the request reached the DHS National Operations 
Center, it was not processed because the responsible individual(s) or PEP Program staff could 
not be located. Additionally, the staff in the DHS Homeland Security Operations Center 
(HSOC) appeared not to be familiar with the PEP program or process. Thus, a major delay in 
deployment of the PEP was encountered, while the National Operations Center tried to locate 
someone who knew about this program. More detailed procedures employing the HSOC as the 
request point of entry and training from DHS for requesting deployment of the PEP could help to 
ameliorate this in the future. 


For more information, see “Data Collection anti Coordination" in the Special Topics section. 

It is possible that a unified command was established before this time, but the evaluation team does not have any 
such data. 

It is also likely that this briefing or any other at this level did not include representatives from the technical 
agencies collecting radiological data since they were working for the Hazardous Materials Chief, not the Incident 
Commander. For more information, see the Special Topic on data coordination. 


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The presence of the Principle Federal Official (PFO) in both venues, but particularly in the 
Washington venue, proved to be an effective conduit for improving coordination among the 
multiple agencies and multiple governmental levels of response. Other good practices in 
coordination during the FSE included the following: 

• There were several examples of agencies and jurisdictions coordinating to solve 
problems. For example, in Washington, the Seattle HOC worked with the Washington 
Department of Transportation and the Washington State Patrol to develop and implement 
a plan to decontaminate and re-open highways. In Illinois, the EOC structure proved 
valuable when the State EOC activated Illinois law enforcement mutual aid to provide 
Chicago additional security personnel in anticipation of a shortage of city workers; 

• There are numerous examples in both Washington and Illinois of State, county, and local 
EOCs conducting conference calls and VTCs. In many cases, these conferences included 
regional representation of Federal agencies, including the regional FEMA Regional 
Operations Center (ROC). In both venues, the PFO also initiated regular conference calls 
with State and local top officials. In the Interagency venue, both the SIOC and the 
DHS collected information from and distributed inftwmation to other Federal agencies. 
Federal agencies and departments also participated in conference calls and VTCs 
involving many different departments and agencies and communicated between agency 
headquarters in Washington, D.C.. and their regional counterparts; 

• During the FSE, there were several good practices of standardized information sharing. 
All FSL agencies with permission to access the Department of Energy (DOE) National 
Atmospheric Release Advisory Capabilities secure Internet site could download 
predictions of the radiological plume. Also in Wa.shington, the Seattle and State EOCs 
shared information through an Internet-based system. However, neither the King County 
EOC nor Federal agencies had access to tiie system, which limited its value. In Illinois, 
DuPage County utilized the Pro-Net surveillance system to track hospital calls and 
admissions and to provide early alerts to possible disease outbreaks; and 

• The FSE provided unusual opportunities for the inclusion of some organizations not 
typically included in response organizations. In Washington, the American Red Cross 
staffed the Seattle, King County, and Washington Stale EOCs, which is not unusual; 
however, they also staffed the Federal Joint Operations Center (JOC) which was 
unprecedented. Their national headquarters was also involved at the interagency level. 
Also in Washington, the Bank of America co-located an EOC with the Federal Reserve. 
Finally, the months of planning allowed Seattle businesses to develop or broaden 
relationships with the emergency response community. They are now in the process of 
establishing the Business Emergency Network (BEN) to increase the business 
community's awareness and involvement in emergency response. 

• The need for advance coordination among agencies, such as the CDC and FDA, on the 
availability of medical countermeasures for humans and animals for other potential threat 
agents is critically important. The TOPOFF Exercise Series offered numerous 
opportunities to do this. 


For more information, .see the Special Topic on the Principle Federal Official. 


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Exercise activities that took place in Canada are beyond the scope of this AAR, but there were 
several examples of U.S. communications and coordination with Canadian authorities. The 
International Office within DHS communicated regularly with Canadian government officials as 
well as government officials from other nations. In addition, after the ROD explosion, DOE 
Headquarters requested radiological assistance from Canada. As a result, Canadian officials 
asked to place a liaison in the Region X ROC. 

c. Connectivity 

A variety of means were used to communicate during the FSE. While there was an increasing 
use of Internet-based transmissions, there continued to be heavy reliance on faxes particularly in 
the case of the Illinois hospitals. Table 16 provides examples of some of the typical connectivity 
issues that arose during the exercise. An issue of concern at the federal level not indicated in the 
table was the difficulty some agencies had receiving and passing classified information. 

One issue that was not identified during the seminars or the Large-Scale Game was the potential 
for technical challenges. During the FSE several such challenges arose. In Washington, the 
Department of Health Radiation Monitoring and Assessment Center had poor connectivity and 
was forced to distribute data primarily via phone, fax, and with a courier. The DOE FRMAC in 
Washington communicated with and transferred information to their servers in Nevada through a 
56K modem, which they reported as much too slow and unreliable. The Advisory Team''” also 
had technical limitations — they had one phone line, which was also their Internet connection.'**^ 
In addition, the Federal JOC in Washington had inadequate VTC capabilities. All of these 
connectivity challenges had an impact on the ability of technical experts, agencies, and 
jurisdictions to communicate effectively. 

In Illinois, the lack of a robust emergency communications infrastructure was manifest by a 
reliance on telephones and faxes for patient data transmission. Often, however, the fax machines 
were unreliable and there was no certainty that the transfer was successful, or there was 
inadequate staff to monitor them. In addition, if the phone lines were compromised, then the 
distribution of data would be severely compromised.'’*^ While in some cases, these connectivity 
issues may have been due to the fiscal and physical constraints of the exercise, this was not 
always the case. Many organizations referenced the critical need for better, more robust 
connectivity (i.e., internet acce.ss) in their Lessons Learned reports. 

3. Conclusion 

As described in detail in the Special Topics section, the communications, coordination, and 
connectivity challenges had an impact on the information available to top officials, which in turn 
affected their ability to make decisions. In all three venues, top officials made decisions based 


The Advisory Team consists of representatives from Federal agencies and provides the lead Federal agency with 
advice on environmental, food, health, and safety issues that arise during and from a radiological emergency. 

*''■ The Federal Radiological Monitoring and Assessment Center and Advisory Team informed the evaluation team 
that these technical limitations are real-world — not exercise artificialities, as they set up wherever they find 
appropriate space. They reported working toward a mobile, high-speed system, but they have to be sure that it 
meets their technical and security needs. 

Because of a lack of coordination observed during the FSE, the connectivity challenges discussed above are the 
not the primary cause of the communication challenges observed during the FSE. For more information, see “Data 
Collection and Coordination”, “Hospital Play”, and Decisions Under Uncertainty” in the Special Topics section. 

For more information, see the Special Topics section on hospital play. 


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upon inconsistent and often incomplete information. Such inconsistencies also made it to the 
public (see the Core Area on public information), which has the potential to compromise the 
credibility of top officials. While better coordination and communications may not lead to better 
decisions, top officials should be confident that they are basing their decisions upon the most up- 
to-date and valid information available. Although it is doubtful that communications, 
coordination, and connectivity will ever be perfect, exercises, including the TOPOFF Exercise 
Series, can serve to identify areas where communications, coordination, and connectivity can be 
improved. 

Although there were significant communications, coordination, and connectivity challenges 
during the FSE, players and planners reported that the building-block proces^llowed them to 
develop new or stronger relationships with their colleagues. Many hav^developed 
implemented processes based upon their T2 experiences to improve their Icom^nications, 
coordination, and connectivity capabilities. 





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D. Jurisdiction 


1. Introduction 


Metropolitan-area providers of emergency services typically 
have interlocking mutual-aid agreements or emergency 
assistance compacts that clarify jurisdictional issues. But 
teiTorist attacks using weapons of mass destruction (WMD) 
bring into play entities and considerations not normally 
encountered and not necessarily provided for in these 
agreements. Authorities that seem clear on paper are not 
always as clear in practice as real-world experiences and 
exercises repeatedly demonstrate. Previous exercises, such as 
Top Officials (TOPOFF) 2000, and real-world events, such as 
9/11 and the anthrax attacks in 2001. highlighted such 
challenges. In this section, we examine the issues, conflicts, or 
gaps in Jurisdictional authorities and the assumptions that arose 
when policies and agreements were pul into practice under the 
uniquely challenging conditions of simulated terrorist WMD 
attacks. 



2. Discassion of challenges and good practices 

Participants raised and examined jurisdictional issues throughout the cycle of T2 including the 
FSE. Table 17 depicts the challenges, and good ptractices relevant to Jurisdiction that arose in 
the seminars, as well as the instances that show how these issues played out during the Full-Scale 
Exercise (FSE). Instances are occurrences experienced by participants during the FSE that 
indicate challenges or good practices a.S50ciaied with particular issues. In the table, a (-) is used 
to indicate challenge, and a (-•-) indicates a good practice. A ( ) is u.scd to indicate a neutral 
observation in the FSE — one that is neither a good practice nor an issue. Good practices are 
those practices that players felt were effective, or that the data indicate worked well;'"’* these 
practices could potentially be explored further or promulgated on a broader scale. Challenges 
ore examples of the T2 response that were difficult for the responder community and which had 
significant impact on decision-makers. Challenges do not imply wrong actions or incorrect 
responses by any organization or the community at large — this After Action Report (AAR) and 
the analysis as a whole did not focus on evaluating right and wrong actions. Challenges require 
continued attention of the national response community to facilitate smoother responses in the 
future. 

During the T2 FSE, there were many successes in the jurisdictional arena; however, the issues 
that were experienced emerged in two overarching areas: 

• Confusion over who has authority for what actions/decisions; and 

• Authority for the control and dissemination of information. 


145 


References in the table are based on specific references in the data. Just because something is not specified as a 
good practice does not mean it did not go well in participants' opinions or did not happen. 


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Table 17. Jurisdiction Issues during T2 


Issues 

Seminars/LSG 

FSE Instances 

Good practices and challenges 

Emergency Public 
Information 

Radiological 
Dispersal Device 

Bioterrorism 

Direction <& 
Control 

Large-Scale Game 
Consequences 

a. Confusion over roles and authorities. 

Some agencies seem to have duplicative 
roles under certain circumstances. 

Plans are sometimes duplicative, or in 
conflict. 

Some authorities are unclear in 
bioterrorism response. 

✓ 

✓ 

•/ 

✓ 


( ) Issues durii^%C|^ull-ScaJe'^^ 
Exerci.sc were less Sinrfdisputes 
ovwwte^ in char^jl^^ather 
wlio is incHarg^wbat. 

(-l^Questioi^l^se concerning the 
u^aPbaent of I^meland Security 
'^d its relaioDship with other 
agiMKies. 

1 ^-) Some questions with 
hoplications of bioterrorism and 
the declaration of a public health 
emergency. 

(-) Some uncertainty regarding 
transportation authorities. 

b. Authorities to release information. 

✓ 

✓ 


✓ 


(+) Regional Joint Information 
Center concepts implemented. 

(-) Frustration at Federal agencies 
releasing "local” messages. 

(-) Control of information can have 
an impact on other activities. 

See "Emergency Public 
Information" core area. 


a. Confusion over rol^ and authorities 

The primary question relating to jurisdiction during the T2 series of activities evolved throughout 
the exercise cycle from who is in charge to who is in charge of what. Participants increasingly 
clarified that the issue in emergencies is often not turf battles, but rather uncertainty among the 
various entities involved in response to multiple, sometimes overlapping, authorities that are 
driving the numerous actions being simultaneously and urgently addressed. From a 
jurisdictional perspective, many things went more smoothly during T2 than participants 
expected. For example, during the post-FSE tabletop held in Seattle, the spokesperson from the 
City of Seattle stated: “During T2, I expected to see a chaos of power that would hamper the 
response effort — these expectations were profoundly uirniet as all levels of government and 
agencies came together to respond to this crisis.” This was exemplified by the transfer of control 


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of the RDD site in Washington, first to the Federal Bureau of Investigation (FBI) once Seattle 
Fire Department completed rescue and recovery operations, and then through the Federal 
Emergency Management Agency (FEMA) back to the local authorities when the FBI completed 
the crime scene investigation. 

However, beyond the RDD incident site there were instances of agencies not knowing who had 
what authority to make certain decisions (see the “Emergency Decision-making and Public 
Policy” Core Area). For example, in Illinois there were multiple discussions regarding who was 
in charge of the decontamination process, who had the authority to re-open the facilities where 
plague was released (the United Center, O’Hare International Airport, and Union Station) and 
who had the authority to define the requirements that must be met to re-open the contaminated 
sites. This last point is particularly troublesome since it involves both an assessment of when it 
is scientifically “clean" versus be perceived as safe by the public. This issue was also relevant in 
Washington as long-term remediation and restoration of areas with radiological contamination is 
a significant public health and environmental protection challenge. These, and other long-term 
issues, were discussed among Federal, State, and local (FSL) agencies and departments in WA at 
the post-FSE tabletop on May 15, 2003. 

Jurisdictional authorities related to transportation were also unclear during the FSE. During T2 
some confusion arose among participants as to who had what authorities to close and re-open 
airspace, rail systems, and road systems. In the case of airspace, there was .some confusion as to 
whether authority to close and re-open airspace and temporary flight restrictions lay with the 
newly-created Transportation Security Administration (TSA) or the Federal Aviation 
Administration (FAA). TSA and Veterans Administration logs indicate that TSA implemented a 
shutdown of airspace in the Seattle area, restricted flights, and closed airspace within 30 miles of 
the three area airports. Other logs from FEMA, Department of Transportation (DOT) Crisis 
Management Center, and FAA indicate that only FAA had this authority. There was also 
confusion regarding the authority to close airports. Some participants, including those from 
FEMA. believed that only DHS had this authority. In fact, the local airport authority has 
jurisdiction over the status of their local airports. 

Discussions occurred within DOT about the legal authority of TSA to close rail systems 
(currently only private rail operators have this authority for freight, while DOT has some 
influence over Amtrak). In addition, FEMA reported to DHS that the U.S. Coast Guard (USCG) 
had closed down the Port of Chicago, and a DHS Crisis Action Team (CAT) log noted that the 
Customs and Border Patrol had closed the Port of Seattle — when actually, only the Captain of 
the Port has this authority (a USCG log notes thi.s). The USCG clarified the authorities of the 
Captain of the Port at the Washington venue Hotwash noting that “knowledge of these 
authorities would be very helpful to emergency responders.” These USCG authorities — to close 
the port. Slop all work at all waterfront facilities, control all vessel movement including freezing 
them in place, to order vessels to leave, and require .significant increases in security at private 
waterfront properties — take on potentially national and international significance within the 
context of a terrorist WMD attack. 

There were also some issues about who could re-open road systems. In Washington, the City of 
Seattle’s Mayor was anxious to restore the city to normalcy as soon after the attack as possible, 
and publicly announced that the roads would be opened at a specified time. However, this 
announcement had not been coordinated with the WA DOT, which has the statutory authority for 
these decisions. Based upon the guidance of the WA State Department of Health (DOH), WA 


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DOT did not agree with the Mayor’s decision. The issue was coordinated and resolved in the 
end but led to hours of confusion by many agencies as to the status of major highways in the 
area. 

The FSE provided a valuable opportunity to identify and explore potential Jurisdictional 
questions relating to DHS’ the newly merged federal assets. For example, in Illinois, some 
issues arose with the declaration of a public health emergency by the Department of Health and 
Human Services (HHS). Such a declaration gives HHS the authority to deploy resources on its 
own initiative and at its own cost. This led to some confusion among agencies concerning the 
status of the Strategic National Stockpile (SNS). The decision to deploy the SNS is made by 
DHS in coordination with HHS. During T2, the HHS headquarters and DHS officials both gave 
directives regarding the SNS; SNS deployed based on DHS directives. There was no apparent 
coordination between DHS and HHS headquarters regarding activation and deployment of the 
SNS; rather, coordination occurred between senior CDC and FEMA officials. This level of 
coordination limits the ability of both departments to effectively manage the full scope of assets 
available for the response effort. 

DHS now maintains many of the medical response as.sets formerly maintained and managed by 
HHS such as the SNS and the NDMS. HHS is the lead technical agency for public health and 
medical emergencies, yet retained few operational assets to respond to such emergencies 
following the creation of DHS. Furthermore, the medical expertise required for effective 
management of these assets is split between the two departments. It is not clear from the FSE 
whether this would impact HHS' ability to manage a response following a declaration of a Public 
Health Emergency in the absence of a presidential disaster declaration — given that it doesn’t 
retain operational control of response assets. Further, the FSE did not stress the federal system 
enough to analyze how difficult decisions regarding allocation of health and medical assets 
would be made. 

FEMA Headquarters was challenged to refute their relationship with their new parent 
Department, DHS, during the FSE. One email suggested that the FEMA Emergency Support 
Team (EST) was not included in a teleconference with the DHS CAT and therefore was kept out 
of the loop regarding the response. In addition, the EST felt that DHS was deploying assets 
without going through the proper notification channels. Furthermore, the roles and 
responsibilities of the new DHS Principle federal Official (PFO) are not well-defined relative to 
the FEMA Regional Directors and the Federal Coordinating Officer (see the “PFO” Special 
Topic). The Environmental Protection Agency (EPA) also noted in the Washington venue 
Hotwash the need to work through and define EPA and DHS authorities and to define who has 
jurisdictional responsibility to take leadership of developing and maintaining health and safety 
plans for all of the different entities involved. EPA also noted that the process and jurisdictional 
roles in tasking partners for support was unclear at times. EPA can respond to a local fire 
department under the National Oil and Hazardous Sub.stances Pollution Contingency Plan, but 
during the FSE, the regional EPA office felt pulled by the national command structure to 
coordinate their response with the Federal response 

Finally, while these were not played out during the FSE, some agencies did highlight potential 
jurisdictional issues that may have been faced in the longer-term recovery phase. EPA raised 
concerns at the Washington venue Hotwash in regards to balancing crisis and consequence 
management, especially in the context of ensuring worker safety at the site, and the potential 
safety of citizens on/near site. In the aforementioned tabletop exercise in Washington on May 


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15, 2003, agencies noted uncertainty as to who makes “large, expensive” decisions regarding 
restoration of infrastructure such as waste-water system and roadways that cross jurisdictional 
boundaries. In another example, local police acknowledged during the Washington venue 
Hotwash that while jurisdiction went well overall, there were some questions relative to FEMA 
in the recovery stage, such as “would FEMA be in charge [of] the field?” 

b. Authority to Release Information 

The authority to release information and the “authoritativeness” of that information was a 
dominant issue during T2. Leading up to the FSE, participants had focused largely on this issue 
with respect to public information, noting concern in numerous seminars about jurisdictions 
“speaking” beyond their jurisdictional boundaries. This is especially problematic when a 
disaster crosses jurisdictional boundaries, as was the case in both the RDD and bioterrorism 
attacks. As DuPage County pointed out in its Les.sons Learned report, “political problems 
existed with multi-jurisdictional release of information, especially with varying levels of 
government.” DuPage County noted that these issues were amplified when Washington State 
issues came into play. As participants at the After Action Conference noted, the public will not 
know which source to believe when government officials relea.se conflicting information. 

Regional Joint Information Center concepts can help to mitigate these issues, as was seen in the 
Illinois venue and as was implemented on a more limited scale in the Washington venue. 
Broader joint information systems concepts offer the potential to strengthen this public 
information coordination to proactively include geographically disparate partners. During T2, 
there were some instances of Federal agencies appearing to release messages without 
coordinating fully with State or local officials. These issues are discussed in more detail in the 
Emergency Public Information core area. 

An additional issue not discussed in the seminars or Large-Scale Game (LSG) arose during the 
FSE and concerned the “aulhoritativene.ss” of information. This issue refers to the reality of 
multiple agencies collecting and exchanging numerous types of information in any response 
effort, and the critical ability of agencies to understand who the authoritative sources are for what 
information. 

In the Washington venue, there was confusion with the coordination of radiological data by 
multiple agencies — all of whom had some authority for the data they were collecting, but the 
result was confusion among the many agencies that received these data and were uncertain which 
information was correct or “authoritative.” Similar confusion was experienced by agencies 
sending and receiving the various plume models and projections that were developed during the 
FSE; some of which was caused by a lack of understanding as to who was the authority for this 
information. Interestingly, numerous data collector logs suggest that those agencies that 
generated their own models knew that the DOE was the lead technical agency in Washington. 
But, when asked whose model everyone should be u.sing, most agencies answered simply that 
theirs was the valid one.*'*® 

In another instance, agencies experienced frustration obtaining ground truth on numbers of 
injuries and fatalities at the scene of the RDD blast. Multiple organizations were requesting 
updates on this information from public health authorities and incident command, which were in 


For a more detailed explanation of the multiple plume models, see the data coordination story in the Special 
Topics section of this After Action Report. 


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turn receiving updates from on-scene responders. But these various sources all had conflicting 
information. Public Health Seanle/King County (PHSKC) noted at the venue Hotwash the 
importance of defining key, credible sources of information that they can rely on since people 
look to PHSKC for answers. It noted that it is only Medical Examiners who can officially 
declare deaths, but official certification may not come for days in the event of an RDD 
explosion. PHSKC highlighted the need to find an appropriate way to provide messages about 
death counts that are yet to be confirmed by the medical examiner.'^ 

3. Conclusions 

The FSE demonstrated that jurisdictional policies and the extent to which they are understood by 
various entities drive and influence every element of response. They define what actions 
agencies believe they are supposed to take. T2 demonstrated the critical importance of clearly 
defining and understanding informational authorities as well. 

Participants at all levels of government continue to state that exercises such as TOPOFF remain 
one of the most effective means to convey these understandings and to clarify authorities that 
may appear clear on paper but which are not as clear when implemented under the complex 
conditions of crisis. The WA State Adjutant General summarized jurisdictional challenges and 
solutions at the post-FSE tabletop held in Seattle, when he stated, “our issues are multi- 
dimensional, and not confined to any single jurisdiction — our recovery architecture must 
recognize non-traditional partners.” 

Reiterating the critical importance of continuing to refine the collective understanding of 
jurisdictional authorities, the WA State Adjutant General encouraged all jurisdictions to “do 
serious introspection on TOPOFF, use it as st^e, and pull together multi-jurisdictional 
functional areas to talk about what wc^f^ well throughout that pulsing system and take a hard 
look at the gaps at the seams.” < < 



Mass fatality management and ca.sualty tracking wa.s a real world problem during the response (o the Oklahoma 
City bombing and the 9/1 1 attacks. The Department of Homeland Security, Office for Domestic Preparedness, 
produced a document that discusses these issues. 


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E. Resource Allocation 


1. Introduction 

Resource Allocation challenges require 
decision-makers to weigh conflicting needs 
and determine how best to apportion limited 
resources. The conflicting needs can 
challenge decision-makers within a single 
agency, or can force decision-makers from 
different agencies and departments to work 
together to decide how best to manage 
critical resources that are in short supply 
relative to the demand. Often the solution is 
unconventional. 

A weapons of mass destruction (WMD) event producing 
demands on scarce medical and public health resources, 
become a concern in the Washington venue as part of the 
Exercise time period. 

2. Discu.ssion of challenges and good practices 

j 

Table 18 depicts the issues, challenges, and good practices relevant to Resource Allocation that 
arose in the seminars, as well as the instances thtitshow how these issues played out during the 
Full-Scale Exercise (FSE). Instances-are occurrencei experienced by participants during the FSE 
that indicate challenges or good practices associated with particular issues. In the table, a (-) is 
used to indicate challenge, and a (->■) indicates a' good practice. A ( ) is used to indicate a neutral 
observation in the FSE — one that is neither a good practice nor an issue. Good practices are 
those practices that play^ felt were effective, or that the data indicate worked well;'^** these 
practices could potentially be explored farther or promulgated on a broader scale. Challenges 
are examples of the T2 response that were difficult for the responder community and which had 
significant impact on decision-makers. Challenges do not imply wrong actions or incorrect 
responses by any organization or the community at large — this After Action Report (AAR) and 
the analysis as a Whole did not focus on evaluating right and wrong actions. Challenges require 
continued attentidr of the national response community to facilitate smoother responses in the 
future. 



mass casualties could put enormous 
Resource issues would likely have 
long-teoB recovery, po.st-Full-Scale 




References in the table are ba.sed on specific references in the data. Just because something is not specified as a 
good practice does not mean it did not go well in participants' opinions or did not happen. 


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Table 18. Resource Allocation Issues during T2 


ISSlIiLS 

Seminars/LSG I 

FSE Instances 

Good practices and chali.en(;f.s 

Emergency Public 
Information 

Radiological 
Dispersal Device 

1 

c 

Direction & 
Control 

Large-Scale Game 
Consequences 

a. Lack of consistent understanding among 
Federal. State, and local (FSL) agencies of 
what federal resources are available, how to 
request those resources, and how much is 
available. 



✓ 



(-) Confusion o\^9^icial channel$}B. . 
acquire the Dep^moHDf Health and 
Human Services ()HHS>l!|^ls now at the 
De^ntmsm of Honelo^ Security 
(C^S). 

(•)^[;Kal agenci^ did not always know 
. wJuci^cipabihiiefVere available for 
.■Kquesl. • 

(+)ipfficials elicited actual requireineni.s 
. teleconferences. 

(•) Confusion over the process for 
declarations and in some cases the 
federal assistance they trigger through 
the Stafford Act. 

(+) Coordination of resources in the Stale 
of Illinois to secure sufficient security 
personnel via Emergency Operations 
Centers. 




✓ 



(+) Pre-planning the Strategic National 
Stockpile distribution sites. 

(•*•) Supplementing medical personnel 
with school nurses. 

(+) Preplanning stockpiles of antibiotics. 

(-) Multiple agencies reserved a key 
distribution site. 

c. Handling ^ortages^ limited resources. 






(+) Illinois Governor’s emergency orders 
opened up sources of volunteers. 

(+) Tfie American Red Cross tapped 
supplemental sources to offset shortages. 

(-) In the Washington venue, FSL 
resources would have been stressed 
during the recovery phase, but weren’t 
played out during the exercise. 

{+) DHS concerned with the long-term 
impact of nationwide red alert on 
resources. 

(+) HHS concerned with the long-term 
and widespread impact of pneumonic 
plague. 


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a. Lack of consistent understanding among Federal, State, and local (FSL) agencies of what 
federal resources are available, how to request those resources, and how much is 
available 

During the Full-Scale Exercise (FSE), confusion was observed at local and state levels about 
federal assets and the processes for obtaining them. A few examples are highlighted here; more 
details on this particular issue are explored in the “Proclamations and Declarations” and the 
‘‘Strategic National Stockpile (SNS)” Special Topics sections in this AAR. 

There currently is no single source to help state and local emergency managers or responders to 
determine which federal resources would best meet their needs during an emergency, and there 
are many methods by which State and local governments can request federal resources. During 
the T2 FSE, States often requested specific a,ssets — sometimes requesting in^propriate or 
unnecessary assets in error. For example, in Illinois a request was made for Disaster Medical 
Assistance Teams (DMATs), although assistance from mortuary services and epidemiologists 
was desired. On a positive note, this disconnect was identified and corrected during a conference 
call among the city, state, and regional Federal operations centers. 

In the State of Washington, the evaluation team did not identify any examples of such confusion. 
There are a number of possible reasons for this. One possibility is that Washington has its own 
radiological emergency experts, as well as experience with radiological emergencies and 
exercises involving nuclear power plants. Thus, Washington State emergency responders are 
able to draw upon existing knowledge, experience, and relationships. 

In both the States of Washington and Illinois, there was evidence that State and local agencies 
made requests to the Federal Government based upon what and who they knew, and, that State 
and local governments do not know oil of the federal resources that are available. These 
informal methods are not the most efficient way to obtain the necessary resources, and in some 
cases did not result in the most appropriate resources for the task. 

There are many methods by which federal assets can be requested. Requests can go directly to 
agencies , or federal departments including the Department of Homeland Security (DHS) once 
they are involved.'"*^ Because resources are requested and deployed from different sources, it 
can be difficult for the Federal Government to track and cor)rdinate the many federal assets in the 
field. This can make it challenging, if not impossible, for decision-makers to weigh all of the 
available information about resources as they become depleted because the decision-makers 
might not have complete information on what remains available. 

This is not to suggest that the many processes for requesting assistance be replaced with a 
centralized system. In fact, these multiple avenues for requesting assistance are critical for a 
number of reasons, including situations for which disasters are not declared, and for ensuring that 
assets arrive at disaster scenes before official Presidential Declarations are signed — the latter of 
which occurred during T2 (e.g., Seattle Fire Department requested assistance from EPA not long 
after the explosion, and Washington State made a direct request to DOE to deploy the Federal 
Radiological Monitoring and Assessment Center (FRMAC)). FEMA currently tracks and reports 
the use of federal assets in a disaster through its Mission Assignments and Situation Reports, but 


It is currently unclear, or possibly undetermined, whether such requests should go through Federal Emergency 
Management Agency and the Federal Coordinating Officer, or through the designated Principle Federal Official 
(PFO) or delegate. See the Special Topics section on the PFO for more information. 


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distribution of these reports is fairly inefficient — usually transmitted through e-mail or fax. 
There does not appear to be a “one-stop shop” where FSL agencies can obtain information 
regarding the range of assets that are available, how to obtain those assets, or the status of assets 
once deployed. A web-based, searchable database of all available federal resources (potentially 
expanded to include slate and local resources at some point), including their names, acronyms, 
capabilities, and request processes — a distributed yet coordinated knowledge base — may be 
helpful and may also minimize personnel requests based solely upon “what and who” an 
individual knows. 


b. Planning for effective use of resources in emergencies 


Planning prior to the FSE'^ appeared to facilitate some of the FSE activities. In Illinois, 
planning for receipt and distribution of SNS medications resulted in a fairly smooth-running 
process. In contrast, shipment and distribution of the Strategic National Stockpile'^' did not go 
as smoothly in the TOPOFF 2(XX) exercise. This reflects in part the tremendous investment in 
planning and preparedness that has occurred in .state and local public health departments since 
the fall of 2001. In particular, bioterrorism preparedness grants awarded by HHS to state public 
health departments in 2002 spurred the development of SNS distribution plans among many 
other activities. The success of the SNS distribution during T2 provides one of many examples of 
how potential improvements in the nation’s emergency response system can be examined in the 
TOPOFF Exercise Series. 

c. Handling shortages of limited resour 

A shortage of prophylaxis for first responders’ljoupled with a concern for unusually high 
absentee rates led Chicago area officials to predict a diortage of personnel available for security. 
When the City of Chicago requested security support from the Illinois National Guard, they 
learned that this resource was unavailable — the troops were deployed in Iraq. Fortunately, the 
city was able to obtain the needed security personnel from neighboring jurisdictions through 
existing mutual aid agreements. While this met Chicago’s short-term needs, it is not known 
whether this solution would be sustainable over a greater time period, as the outbreak spread and 
as neighboring jurisdictions recognized their own needs for security. T2 did not evolve to this 
level of play to allow greater insight. 

Responders obtained via mutual aid agreements also supported Seattle’s response. For example, 
the State Fire Services Mobilization Plan was mobilized to support local firefighters. In addition, 
Seattle had 14 engines, four ladders, and 21 police cars that were contaminated and impounded. 
This equipment was expected to be replaced by neighboring jurisdictions using mutual aid 
agreements. The mutual aid partners, however, were concerned about the length of time that 
Seattle would need the loaner equipment. This concern was especially relevant because unions 
told Seattle (notionally) that they would suggest their members not use previously contaminated 
equipment. They were concerned that “clean” wouldn’t really be clean. 



The evaluation team is not privy to whether this planning wa.s specific for the T2 exercise, or whether it is 
consistent with real-world planning for emergencies. 

The National Pharmaceutical Stockpile was renamed the SNS when it became part of DHS. 

Note that the definition of clean/dea)ntaminated was brought up in seminars, the LSG, and in the Washington 
venue tabletop exercise. In these discussions, players were not convinced that the public would be comfortable with 
places and equipment deemed “safe” after decontamination. 


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In some cases, it is possible to circumvent potentially limited resources by expanding the 
resource pool. During T2, this circumvention was done in two ways; 1) by relying on 
unconventional sources of support, and 2) by intervening with executive orders that exempt 
individuals from repercussions (often legal battles) that would otherwise prevent these 
individuals from providing services. For example, the American Red Cross requested mental 
health counselors from the Chicago Public School system to fill in for its predicted 20 percent 
absentee rate. Also in Illinois, the Governor signed several emergency executive orders that 
restricted liability and provided immunity to people supporting the response. One was 
particularly valuable for SNS distribution: it allowed non-pharmacists to dispense prophylaxis. 

One of the many challenges in managing limited resources is working to maintain enough 
resources to handle other yei-io-occur situations — predictable or otherwise. To meet this 
challenge, those who make allocation decisions need to decide what, if anything, they should 
hold back from immediate requests to ensure there are resources to support other needs, should 
they arise. Such planning requires a risk a.ssessment, and, in the case of bioterrorism, expertise 
on how and how quickly the disease can spread. Such planning requires difficull choices, as it 
could lead to unfortunate illness and even death. However, it can also avert nation or worldwide 
spread of epidemics. There is evidence of such planning during T2. In one example, the DHS 
Emergency Preparedness and Response Directorate was working on a plan to distribute drugs 
from the SNS to other states that requested the stockpile, recognizing the inevitable spread of 
cases outside Illinois. In addition, public health ol^cials in Illinois anticipated potential hospital 
surge requirements that the growing epidemic would require (see “Decision Making Under 
Conditions of Uncertainty” in Special Topics). The Severe Acute Respiratory Syndrome (SARS) 
outbreak has caused public health authorities to think about how to provide surge capacity. Of 
course, in the event of bioterrorism, an outbreak could be much more severe. In Washington, 
the National Guard Civil Support Team was released from the incident site and placed on 
standby in case they were needed to respond to another incident. Thus, officials at all FSL levels 
were developing plans to handle the unpredictable. 

3. Conclusions 

For a variety of fiscal and operational reasons, play in Washington was limited and did not fully 
stress the system. For example, field play ended after two days, and exercise play ended after a 
command post exercise on the third day (D+2). The result was that many resources that are often 
exhausted early in the response either did not need replacing or were not exhausted. In addition, 
prior to the FSE, the Washington venue chose not to play the plague scenario — which meant that 
the two incidents did not interact, except in terms of the criminal investigation.'^^ In fact, during 
the exercise HHvS sent at least one inject via fax to Public Health Seattle/King County (PHSKC) 
Department regarding plague patients. PHSKC responded that it was not playing the plague 
scenario because of real-world resource limitations on public health workers stemming from 
SARS and the smallpox vaccinations.'^ Players in the Washington State Emergency Operations 
Center commented that they would have been very challenged if they had played the plague 
scenario. Furthermore, levels of radiation were designed to be relatively low to impose relatively 


Note that early incarnations of the scenario had plague coming to Washington State, but the radiation from 
Seattle was never conceived of as being transferred to Illinois. 

Near the end of the exercise, participants at the King County and WA State EOCs took actions related to the 
plague outbreak. 


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minimal impact upon the community. Nonetheless, Washington resources were stressed and 
requests were made for assistance from mutual aid partners and federal resources. Furthermore, 
some federal assets, such as the FRMAC, reported that they were having difficulty meeting all 
requests. 

In Illinois, issues of limited resources were anticipated, discussed, and planned for, often with 
creative and unusual solutions. Federal resource managers also predicted and planned for 
resource depletion through decision-making that would likely be unpopular. This type of 
planning suggests that the Federal Government was prepared to make difficult donjons that 
might be needed following terrorist events. 



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F. Anticipating the Enemy 


]. Introduction 

The existence of an enemy makes the response to terrorism attacks qualitatively different from 
the response to any natural or conventional disaster. For example, the desire to keep terrorists in 
the dark regarding response plans can work against the desire to keep the public informed. 
Nature is morally neutral and indifferent to its own effects. Terrorists, however, can exploit 
government and public reaction to an attack, and this consideration must be taken into account. 
Media reports, some of them quite detailed, describing adjustments being made by the 
Government in the wake of 9/11, were criticized for making too much information available to 
the terrorists. While an active Red Team during the Top Officials (TOPOFF) 2 (T2) Full-Scale 
Exercise (FSE) was limited in scope, the actions of responders and top officials can still 
demonstrate awareness of potential follow-on attacks. This area of analysis focuses on those 
actions discussed in the seminars and observed during the FSE that related to the need to 
anticipate the enemy. 

2. Discussion of issues: challenges and good practices 

Table 19 depicts the issues, challenges, and good practices relevant to Anticiputing ihe Enemy 
that arose in the seminars, as well as the instances that show how these issues played out during 
the FSE. Instances are occurrences experienced by participants during the FSE that indicate 
challenges or good practices associated with particular issues. In the table, a (-) is used to 
indicate challenge, and a (+) indicates a good practice. A ( ) is used to indicate a neutral 
observation in the FSE — one that is neither a good practice nor an issue. Good practices are 
those practices that players felt were effective, or that the data indicate worked well;'^^ these 
practices could potentially be explored further or promulgated on a broader scale. Challenges 
are examples of the T2 response that were difficult for the responder community and which had 
significant impact on decision-makers. Challenges do not imply wrong actions or incorrect 
responses by any organizatibnjOMhe conwunity at large — this After Action Report (AAR) and 
the analysis as a whole didknorfSEu_s^ evaluating right and wrong actions. Challenges require 
continued attention of the national response community to facilitate smoother responses in the 
future. \ 



References in the table are based on specific references in the data. Just because something is not specified as a 
good practice does not mean it did not go well in participants' opinions or did not happen. 


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Table 19. Anticipating the Enemy Issues during T2 


Issue 

Se.wsaks/LSG 

FSE 

Good practices and challenges 

Emergency Public 
iiifornuilion 

Radiological 
Dispersal Device 

Bioterrorism 

Direction & 
Control 

Large-Scale Game 
Consequences 

a. Balance public information with securily 
needs. 

1 

✓ 

✓ 


1 


( ) No evidence tosupport or refute. 

b. NEW: Recognition by decision-makers 
that an active malevolent enemy may seek to 
exploit response strategies. 


1 




<+) Showiag caution in rcspcnding to an 
evaii that might have a terrorist origin. 

(+) Proactively mifiing defenses over a 
widespread area ^er one area has had a 
confirmed or strongly suspect terrorist 
aitkir. 

(4) Development of plans to manage 
Uniited resources in the event of another 
attack. 

(-) Several agencies suggested that 
anticipating the enemy is not their 
concern or that it is the responsibility of 
the Federal Bureau of Investigation. 


a. Balancing public information with secuiiQ' needs 

Top officials have to weigh competing factors when deciding to release information that could be 
used by terrorists. These include: 

• The need to anticipate the enemy’s use of available information, and sometimes limiting 
the content of information about the response or other emergency-related activities (e.g., 
shelter locations) that is released to the public; and 

• The need to retain the public’s confidence or even to enlist their cooperation, and 
sometimes make statements indicative of what is known about the enemy, including their 
potential whereabouts, plans, etc. 

b. Recognition by decision-makers that an active malevolent enemy may seek to exploit 
response strategies 

During the FSE, there were a number of responder and top official activities that demonstrated a 
keen awareness of potential follow-on attacks in other U.S. locations and in the already targeted 
locations. Some examples include: 

• Soon after the explosion in Seattle, the Seattle Federal Bureau of Investigation (FBI) field 
office and FBI Headquarters counter-terrorism division initiated an initial threat 
assessment, examining the possibility of other explosive devices in the Seattle area; 


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• The City of Chicago and surrounding counties increased surveillance, and decreased 
parking and deliveries, at pre-selected, likely terrorist targets after the RDD attack in 
Seattle incident; and 

• Nationwide, there were various closures, and increased guards at facilities, such as 
nuclear power plants. 

In Seattle, the National Guard Weapons of Mass Destruction Civil Support Team was released 
from the RDD explosion site at 1230 Pacific Daylight Time on May 13, 2003, in part so that they 
would be available to re-deploy in the event of another terrorist attack, at another place, and at 
another time. Similarly, considerable thought was given to this by the Department of Heaitii and 
Human Services, the Department of Homeland Security, the Centers for Disease Control and 
Prevention, and others to the need to deploy the Strategic National Stockpile and other resources, 
with explicit mention that the Chicago metropolitan area might not be the only area attacked with 
Pneumonic Plague. 

Finally, the increases of the Homeland Security Advisory System Threat Condition from Yellow 
to Orange, and then to Red, whether nationwide or only in particular citie,s coast-to-coast, 
represented the ultimate in proactively raising defenses over a widespread area. 

However, many agencies and jurisdictions acknowledged that they either were not playing 
against an enemy or that it was the responsibility of others (e.g., the FBI and the Joint Operations 
Center) to consider the enemy. The former likely represents an exercise artificiality. Further 
Red Team play was limited to tactical support to the Seattle Police Department Special Weapons 
and Tactics (SWAT) team, the U.S. Coa-st Guard, and FBI SWAT activities in the state of 
Washington, as well as to the Illinois State Police and FBI Hostage Rescue Team activities in the 
state of Illinois. These events did not impact the broader T2 FSE, and therefore Red Team 
activities did not directly impact any decisions made by top officials. Yet. agencies and 
jurisdictions must be aware that their responders will be at risk by nature of being part of the 
response. The loss of responders in additional attacks could seriously impair an agency’s or 
jurisdiction's response capability, not to mention how such a loss would impact the morale of 
other responders and the public at large. 

3. Conclusions 

Despite the fact that the exercise contained limited Red Team play, many participants did 
consider the possibility of further terrori.st attacks. Examples of their doing so exceed the few 
cited here. 

The question of how to respond to an event that seems to have been an act of terrorism, but is 
lacking conclusive proof, is problematic. This was faced on 9/1 1 and in the wake of the anthrax 
attacks in 2001. Officials need to strike a delicate balance among all the competing demands of 
protecting the public in both response and prevention. 


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VII. A COMPARISON TO TOPOFF 2000 


This section compares Top Officials (TOPOFF) 2 (T2) to the earlier TOPOFF 2000 Exercise. 
TOPOFF 2000 resulted in a substantial and valuable Exercise Observation Report, which should 
be consulted for further details on TOPOFF 2000 findings. 


A. De.sign 

The Full-Scale Exercises (FSE) in both TOPOFF 2000 and T2 featured; 

• Top official participation; 

• A city with a pneumonic plague event; 




tv 




Another city with an explosion/hazardous materials (HAZMAT^vent:'in TOPOFF 2000 
a bomb was detonated relea.sing a persistent chemical ^ent^ ^Por tsmouth; in T2 a 

I* 1 • 1 •' <1 * f . . I - t 


radiological dispersal device (ROD) was detonated in ^eattle;^and 
Interagency play at the command post level in Washingtoi 


muc^nu 

oV^t, 


Despite the similarities of design between TOPOFF exercises, there were major 

differences. T2 added an international elemen^not present in TOPOFF 2000. by including some 
international elements in the scenario and throuel^anadi^govemment participation. 

The designers of T2 responded to some of the TOPOFF 2000 participant feedback, most notably 
by: 



• Facilitating the increased involvement ofTOp officials; 

• Eliminating TOPOFF 2000’s “ntJrnotice” character in favor of an open exercise in which 
participants were introduced to the>xercise scenario through a cycle of exercise activities 
of increasing complexity that, included seminars and a large-scale game (LSG); 

• Introduction of a limited opposing force, or Red Team, to develop the concept and rules 
of play so that a more robust Red Team could be employed in future exercises; and 

• Giving increased attention (via the LSG) to long-term recovery issues. 

Exercise planners in the venues actively participated in the design of the scenario. The full- 
notice, “open-book” nature of the T2 FSE also helped to allay participants' concerns that they or 
their performance would be evaluated. However, these changes brought about some post- 
exercise criticism in the media that the “open book” nature of T2, including extensive exposure 
of the participants to the scenario in the seminars, minimized free-play decision-making. In fact, 
the designers deliberately chose to maximize continuous learning rather than sequestering the 
scenario. 


This early involvement in design paralleled another path of continuous pre-FSE participation, 
namely that of the seminars and the LSG. These used the same scenario as the FSE (more 
precisely, each seminar used the FSE scenario as it stood at the time of the seminar), and had the 


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effect of making the participants and the designers more aware of the details of each topic treated 
in the seminars. 

B. Participants 

Despite its designation as a top officials’ exercise, (“TOPOFF,” based upon the term Top 
Officials), TOPOFF 2000 was assessed to have suffered from insufficient top official 
participation. Likely reasons include the conflict between the no-notice nature of TOPOFF 2000 
and the heavily pre-scheduled commitments of top officials. In T2, top officials at all levels of 
government participated actively during the FSE. 

The participating T2 organizations in the Washington and Illinois venues — including local, state, 
and regional federal entities, as well as private organizations such as the American Red Cross — 
are too numerous to list here, but spiecial mention must be made of the remarkable level of 
participation by Chicago area hospitals. Far in excess of the number hoped for, hospitals in the 
metropolitan Chicago area volunteered to participate in the demanding T2 exercise, and did so 
while maintaining their caseload of real patients, who required real care at the same time. For 
this reason. T2 represented an unparalleled opportunity to examine the operation of the public 
health and medical communities in the face of a bioterrorisra attack. This was in significant 
contrast to the limited medical play which occurred during TOPOFF 2000. 

C. Evaluation, and the Data to Make It Possible 

T2 employed a significantly different approach to exercise evaluation in TOPOFF 2000. The 
TOPOFF 2000 Exercise Observation Report is a compilation of the after-action reports of the 
individual participating entities, and the results of an after-action conference held some months 
after the exercise where perspectives on the exercise were obtained and exchanged. Such reports 
and conferences are extremely valuable, and T2 has benefited from having received such reports 
and having had a similar post-exercise conference one month after the FSE (held on June 17 and 
1 8, 2003); but such information and perspectives, while valuable, are not data. 

During the T2 Full-Scale Exercise (FSE), data collectors worked side-by-side with participants 
to document a time-based record of player actions and decisions. These, and other logs kept by 
exercise controllers as well as those created in the course of play by participants including emails 
whose work (and therefore whose FSE play), were combined and sorted by lime. Entries were 
tagged for relevance to the six core areas of analysis and to several of the special topics whose 
importance emerged only as the FSE unfolded. From these records, analysts working on any 
particular area of analysis or topic could quickly find all relevant occurrences and compile a 
corr^rehensive look at the events sorted according to time. This allowed analysts to view the 
interconnections that no single participant or observer would have been able to perceive. 
Importantly, this process traces T2 findings back to the events that actually took place during the 
exercise. As such. T2 effectively represents the baseline exerci.se from which all future exercises 
can be systematically compared. 

D. Findings 

The following sections present a brief comparison of the results from T2 to the findings of 
TOPOFF 2000. In the interest of brevity, the latter are taken entirely from the TOPOFF 2000 


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report’s 14 major areas of observation'^^ and re-arranged to conform to T2’s six core areas of 
analysis. 

1. Emergency public information (EPI) 

TOPOFF 2000 resulted in the following observations regarding public information: 

• “Confusion on EPI roles, responsibilities, and appropriate public messages”; and 

• “Confusion was evident in the chemical venue regarding the role of Joint faformation 
Center (JIC) and Joint Operations Center (JOC) responsibilities.” 

Confusion as to EPI roles and responsibilities for messages emerged as well in T2. For exan^le, 
in Seattle a Public Information Officer (PIO) speaking for the King County Regional JIC said in 
a press conference that there are "no casualties” from the Seattle RDD blast when in fact the 
King County Emergency Operations Center had a casualty count that was over sixty, and 
included two fatalities. Other examples included inconsistent themes in public messages from 
top officials in the Washington venue regarding the relative dangw from radiation; varying 
guidance from agencies regarding antibiotics in Illinois; and at least one press release from the 
City of Chicago requiring proof of presence at the suspected exposure sites as a condition for 
receiving prophylaxis. 

The confusion of JIC and JOC roles does not seem,to have been repeated. 


2. Emergency public policy and decisiommaking 
In TOPOFF 2000: 




• “Authorities and guidance for^ population control and movement restrictions (e.g., 
quarantine) for a large-scale puSlic health emergency are uncertain and not widely 
understood”; 

• “TOPOFF 2000 highligbtecn^ need for improved public health sentinel surveillance 

capabilities”; ^ 

• "The capacity to gauge^^lhe scope and consequences of a catastrophic WMD incident and 
convey that information to senior officials must be improved to facilitate timely and 
appropriate decision-making”; 

• “Lack of, or limited use of. detection equipment was a significant impediment to early 
recognition of chemical, biological, and radiological... WMD attacks”; and 

• "Updates on mitigation efforts must be widely transmitted to both responder communities 
and the public.” 

The contrast between TOPOFF 2000 and T2 in this regard is interesting and deserves 
considerable attention. 


Note that TOPOFF 2000’s usage of the term “observation” does not necessarily conform to the definition applied 
to that word in this T2 After Action Report. 


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As a result of substantially increased public health funding in the wake of the anthrax attacks, 
planning efforts directed towards a possible intentional smallpox release by terrorists, and 
actions taken to prepare for a potential Severe Acute Respiratory Syndrome (SARS) outbreak in 
the United States, considerable thought has been given to the issues of population control and 
movement restrictions. Despite these activities, implementing them in the event of a real-world 
requirement would most likely be a difficult problem. T2 did not exercise this aspect of the 
public health response to a disease outbreak, although policies such as shelter-in-place and snow 
days‘^^ were implemented to protect the population and legal authorities to restrict movement 
were invoked. 

T2 did not fully provide an opportunity to test the efficacy of sentinel surveillance of disease and 
radiological detection systems. Given the large number of initially exposed individuals, the 
onset of the plague in Illinois was sufficiently dramatic that it prevented such a test.^^’ At one 
point there had been discussion of having a more subtle disease onset in the Illinois venue to test 
surveillance systems, but other objectives could only be served by having a large number of 
patients, and those objectives were deemed more important. There were a number of attempts to 
estimate the scope of the plague outbreak in Illinois but this was not fully played out during the 
FSE. Had the exercise continued for one or two more days, the scale of the outbreak would have 
become a significant issue. Even so, at the federal level in the Department of Health and Human 
Services, efforts were underway as the week went along to determine the scope of the disease 
outbreak in order to assist resource planning. 

In TOPOFF 2000, the responders entered the blast site and became contaminated by the 
chemical agent: in T2, by way of contra.st, respoider safety was clearly balanced against the need 
to rescue victims. However, officials may have been challenged if the public complained about 
seeing responders "hanging back” from the incident site. 

The TOPOFF 20(X) report cites national plans (e.g.. the Federal Response Plan (FRP), and the 
Federal Radiological Emergency Response Plan) as needing reconciliation with Presidential 
Decision Directive (PDD)-39, the Domestic Guidelines. T2 took place in the transition to 
Homeland Security Presidential Directive (HSPD)-5 from the existing FRP and concept of 
operations. The creation of DHS and the attendant development of a National Response Plan 
(NRP) and National Incident Management System (NIMS) mean that the next TOPOFF exercise 
will be conducted under different doctrine and policies. As such, further analysis of the exercise 
data can provide additional valuable insight into communications, coordination, and connectivity 
issues that will be important in the development of the NRP and the NIMS. 

Finally, since there is no real-world precedent in which the Stafford Act has been applied to a 
biological disaster— or one involving non-explosive radiological, chemical, or biological 
weapons — it is noteworthy that in both TOPOFF 2000 and T2, the widespread impacts of the 
biological attacks did not qualify as a "disaster,” under The Stafford Act. In T2, this led to a 
declaration of “emergency” in Illinois, when a declaration of disaster was requested by officials. 
The distinctions between the assistance that can be obtained through these two types of 
declarations were not always understood by participants. Future exercises should continue to 


During the T2 Full-Scale Exercise, the phra.se xnou’ days indicated to participants that they were to stay at home 
as if they had been impacted by a major snow storm. 

Although as noted in the special topic on hospital play, the initial indicator of the plague outbreak appeared to 
have come from DuPage County’s Pro-Net surveillance .system. 


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refine the applicability of the Stafford Act to bioterrorism and other non-explosive disasters not 
explicitly defined in the Act, in order to increase Federal, State, and local (FSL) agency 
familiarity with its application to, and implications for, such disasters. 

3. Resource allocation in TOPOFF 2000 

The TOPOFF 2000 report cited shortages of medical and other supplies, and the ensuing 
competition over these supplies on the part of multiple jurisdictions. 

The T2 scenario was designed not to stress resources to the breaking point, so shortage concerns 
did not generally arise. However, there was a potential prophylaxis shortage in the Illinois venue 
that was quickly averted by the introduction of Vendor Managed Inventory. ITje RDD incident 
was not large enough to exhaust the region’s resources at least in the near term. Similarly, the 
exercise ended in the Illinois venue before the most challenging resource demands inqiacted the 
medical system in terms of resources such as beds, ventilators, and staff. 

4. Communications, coordination, connectivity in TOPOFF 2000 

The TOPOFF 2000 report recorded the following observations regarding communications, 
coordination, and connectivity: 

• “Improved interaction is required among U.S. Departments and agencies and 
international organizations ... regarding alerts, notifications, and warnings’’; 

• “Roles and responsibilities in notification (e.g., the National Response Center) were not 
clear’’; and 

• "There was no ability to broadcast collective warnings.” 

These issues remain among the most dominant challenges faced by the national response 
community. The creation of DHS and the development of the Homeland Security Advisory 
System have helped to provide communication frameworks, but numerous challenges remain. In 
T2 these challenges manifested themselves in numerous instances such as the elevation of the 
HSAS to red for the first time in an exercise or the real world, tracking patient numbers and 
casualties both in the Washington and Illinois venues, and coordination of public information 
messages in both venues. Issues remain in the areas of information access, formal and informal 
communications channels across multiple EOCs and with sub.stantial use of internet-based 
communications, insufficient electronic communications infrastructures in some domains such as 
the medical community, and common language, to name a few. 

5. Jurisdiction in TOPOFF 2000 

In TOPOIT 2000. it was observed that: 

• “Roles and responsibilities for operational direction and control... were blurred by the 
proliferation of response teams.” 

Despite the creation of DHS, this observation might resonate with some T2 participants. In 
particular, the role of the PFO in regard to the previously existing resjxmse structure needs to be 
clarified. The proliferation of federal response teams remains an issue — there appear to have 
been more teams in T2 than there were in TOPOFF 2000. Coordinating and effectively using 
these federal assets is an area requiring attention. 


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Plume modeling and deposition analysis problems in T2, and associated data collection and 
coordination issues, can also be viewed as jurisdictional issues. Furthermore, there were 
jurisdictional uncertainties over who had the authority to shut down and re-open the 
transportation infrastructure (e.g., highway, rail, and air systems). 



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T2 


VIII. EXERCISE DESIGN AND CONDUCT LESSONS LEARNED 


The Top Officials (TOPOFF) 2 (T2) After Action Conference (AAC) attendees and exercise 
participants identified several lessons learned relative to exercise design and conduct. After 
assembly and review, comments were compiled into the following eleven subject aret 


Planning, Participation, and Coordination Considerations; 
Intelligence Development and Management Processes; 
Exercise Document Guidelines; 

Exercise Time Standards; 

Exercise Artificiality Considerations; 

Consideration of a Functional Web-based Control Cajkbi 
Additional Exercise Event Considerations; 

Scenario Scripting Considerations; 

Virtual News Network Considerations 
Exercise Security Considerations; and 
Coordination and Venue Design Team Empowerment. 






ect areas: 





A. Exercise Design and Conduct Comment 
This section addresses exercise design and conduct comments as they pertain to each subject 


area. 


V 


1. Exercise planning, cooi^i^tlon^nd participation considerations 

The Secretary of Homeland^Security should continue to solicit participation in the TOPOFF 
Exercise Series by formal invitation, encouraging the direct involvement of top officials at every 
level of Federal, State, and local response, including appropriate non-government organizations. 

T2 AAC participants commented that invited senior officials should commit themselves and their 
organizational resources as early as possible. While T2 gained substantial top official 
involvement, future events would hugely benefit from even greater support from senior leaders. 
Their early and significant commitment immediately increases process relevance and the 
potential for exercise success. The Secretary of the Department of Homeland Security (DHS) 
direction in establishing a national exercise program to be administered by the DHS Office for 
Domestic Preparedness (ODP) will aid participants in .scheduling and scoping participation in 
TOPOFF and other national-level exercises. 


The T2 seminars included many senior officials. Comments suggested the complex process for 
forwarding invitations and coordinating participation requires improvement. Invitations were 
often forwarded within an organization’s executive channels and bypassed the primary exercise 
planner. This process should commence well in advance of suspense dates to ensure that 


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T2 


exercise planners are aware and informed. Primary exercise planners play key roles in preparing 
senior officials for meaningful event participation. 

Many T2 participants were concerned about the relatively late identification and commitment of 
participating organizations. Commitments to scope of participation and statements of support 
requirements must take place earlier in the planning process. T2 planners developed a 
Memorandum of Understanding (MOU) to codify and identify participating organizations, their 
commitment levels, and their administrative and logistical support needs. The T2 MOU was 
completed too late in the planning process to be fully effective. Future TOPOFF Exercise event 
planners should formalize this document as a binding Memorandum of Agreement completed 
prior to significant exercise planning and staffing expenditures, preferably by the Mid-term 
Planning Conference. 

Participant comments suggested that T2 data collector and controller roles and requirements 
were not clearly defined. Qualification guidelines and more specific infonnation regarding their 
duties would enable more appropriate personnel selection and application. Recruitment needs to 
occur early enough to permit sufficient opportunity for their training. 

Several individuals and organizations .suggested including past TOPOFF venue participants in 
future TOPOFF Exercise planning processes. Individuals with first-hand venue experience in 
past TOPOFF events could contribute an important depth of ctxporate memory and insight to 
future events planning, 

T2 included substantial international play, primarily with Canada, reflecting the international 
scope of potential weapons of mass destruction (WMD) events. It was recognized that future 
TOPOFFF exercises should emphasize more international involvement. Consideration should be 
given to inviting key international bodies such as the World Health Organization, in addition to 
other governments. 

2. Intelligence development and management processes 

T2 intelligence play was purposefully designed to provide background support to drive the 
exercise scenario. For sirr^licity. T2 did not provide an opportunity for analytical review and 
intelligence development. Several comments suggested including enough depth and complexity 
of notional intelligence processes to allow for analysis in real time. Such intelligence play 
should enable and promote the intelligence buildup at exerci.se commencement and continue as a 
robust element of play throughout the event. The intelligence community should provide 
answers to requests for information, including the production of “tear-lines” so that DHS can 
produce press releases based upon them. This would support the concept of prevention, an 
important aspect of homeland security. 

Further comments suggested that all exercise intelligence data should be handled within actual 
controlled channels, as it would in the real event. 

3. Exercise documents guideline.s 

Many participants were unclear about T2 scenario control with respect to injects. There was 
confusion as to which were official, and how official requests for information or injects would or 
should be received and processed. Most agreed that participants should use preexisting 
organizational document formats during exercise play just as they would in reality. These 
documents must include appropriate exercise caveat markings that clearly identify them as 


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T2 


notional so they are not confused with actual document traffic. The exercise control group 
should use standardized exercise document formats, recognized by all participants as exercise 
control documents. Establishment of the National Exercise Program and collaborative 
management processes will improve available tools and templates. 

4. Exercise time standards 

Confusion sometimes existed as to time references, particularly as the Master Control Cell was 
in Washington, DC (Eastern Daylight Time), and the venues were in the states of Illinois 
(Central Daylight Time) and Washington (Pacific Daylight Time). Comments suggest 
eliminating such conftision with the mandatory use of Coordinate Universal Time, or Universal 
Time, previously known as Greenwich Mean Time, for all exercise transmissions. 

5. Exercise artificiality consideration.s 

Exercise artificialities occur simply because many aspects of a real situation cannot be 
effectively simulated. The scope of exercise play is limited by funding, logistical and 
geographical constraints; therefore, some artificialities are beyond planner control and others are 
choices specifically made to enable specific exercise goals and objectives. Each artificiality 
should be the product of a conscious choice and provide the means to demonstrable ends. 
Exercise planners should clearly identify and consider each artificiality for its necessity in 
achieving exercise objectives. 

Overall, planners must weigh real exercise factors against versus notional ones. A robust 
firewall between artificial scenario information and real world information must be established 
and maintained at all costs. Realistic deployment timelines and parameters must be maintained 
in cases where assets are positioned admini-stratively to simplify logistics and costs. 

Comments suggested notionalizing additional elements of future events by including first 
responder casualties, more aggressive exercise press coverage and media pressure, Web-based 
news formats, extension of play to include more long-term consequences and recovery 
considerations, and challenges to Continuity of Operations and Continuity of Government plans 
and processes. 

6. Consideration of a functional Web-based control capability 

A serious shortcoming cited in T2 was the failure of planned controlled access communication 
channels and the use of a Web-based Master Scenario Events List (MSEL) tracking tool. In 
short, the Extranet Secure Portal and the on-line MSEL tools did not achieve performance 
expectations. Such on-line exercise control tools must be fully functional and all controllers 
must have ready access and confidence in the tools’ reliability. 

7. Additional exercise event considerations 

While the T2 Full-Scale Exercise (FSE) ended as planned on May 16, 2003, there may have been 
significant utility in a post-FSE event focusing on remediation and long-term recovery aspects 
leveraged from the FSE scenario and play. To exploit similar future opportunities, planners 
should consider the potential of post-FSE events to produce a more comprehensive learning 
experience. Other smaller spin-off precursor or successor events could emphasize prevention 


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T2 


and protection aspects of a WMD terrorist incident as well as response, and engage all potential 
players during a notional intelligence buildup. 

8. Scenario scripting considerations 

Future exercises must closely balance scenario scripting against free play. It is important that all 
controllers clearly understand the definition and function of the MSEL and Procedural Flow 
(PROFLOW) processes. To avoid the premature disclosure of MSEL information that 
occasionally occurred during T2, future events should re-emphasize limited access and 
distribution of MSEL/PROFLOW information, and establish voluntary yet firm non-disclosure 
policies. An organizational exercise planner is a “trusted agent” with regard to the 
MSEL/PROFLOW and as such must protect the data as privileged information, guarding against 
its disclosure to organization members, or players, actually responding to the exercise challenge. 

9. Virtual News Network considerations 

Virtual News Network (VNN) accomplished many successes during T2. Future exercises could 
benefit from some changes and augmentation of VNN operations. The T2 design process can 
improve to ensure VNN announcements and interviews faithftilly correlate with exercise play. 
Another consideration is the cost of VNN play. Though many recommended that VNN 
operations continue around the clock, planners must weigh the value of extended VNN play 
against cost. To add further realness to a simulation. VNN could record and play back its 
broadcasts during off hours, or provide a 24-hour Web-based news source such as 
www.VNN.com. Future VNN efforts should be tai^eted at aggressive news gathering that 
actively seeks sources for stories. 

10. Exercise security considerations 

Awareness of exercise participant safety and security concerns need to permeate exercise 
planning and operation. The po,ssibility that sen,sitive information or closely-held responder 
procedures might fall into the wrong hands needs to be minimized. Enhanced physical, as well 
as electronic, security in the venues and the master control sites should be priorities in future 
events. 

11. Exercise coordination and venue design team empowerment 

Exercise venue design teams could be empowered to make recommendations regarding 
equipment and training preparedness needs, based upon their subject matter expertise and insight 
into existing domestic preparedness programs. The smaller, building-block events leading up to 
the FSE can be used as tools to enable or increase FSE success. These challenges also present 
continuous opportunities to identify State and local training, procedural, equipment, and 
preparedness shortcomings prior to the FSE. Closer linkage to statewide, multi-year Homeland 
Security strategies under DHS/ODP grant programs will improve the ability to identify needs. 


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T2 


IX. CONCLUSIONS 


Following on the success of TOPOFF 2000, TOPOFF 2 (T2) was truly a groundbreaking 
exercise. It was particularly noteworthy as the first national exercise conducted since the 
Department of Homeland Security (DHS) was established. As a result, it provided a tremendous 
learning experience both for DHS and for the Federal agencies that will now be working with 
DHS during the response to domestic incidents. In addition, the experience in Washington and 
Illinois provided important lessons regarding Federal, State, and local (FSL) integration. These 
lessons are valuable to other states and localities as they work to train, exercise, and improve 
their own response capabilities. 

A. T2 involved the play of new agencies and entities within DHS (e.g., the Transportation 

Security Agency, the Principle Federal Ofilcial, and the Crisis Action Team) 

• The F>rinciple Federal Official (PFO) concept was tested in both exercise venues. While 
this position has the potential to assist greatly with the coordination of federal activities 
across the spectrum of the response, T2 results also indicated that the roles and 
responsibilities of the PFO need to be clarified with respect to those of the Federal 
Bureau of Investigation Special Agent in Charge, the Federal Emergency Management 
Agency (FEMA) Regional Director, and the Federal Coordinating Officer, and 
potentially others. In addition, the PFO requires an emergency support team with the 
flexibility and expertise to provide support Mro.ss the full range of homeland security 
operations. Other areas requiring clarification include transportation and medical assets 
now administered through DHS. 

B. T2 represented the first time (real or exercise) in which the Homeland Security 
Advisory System Threat Condition was raised to Red 

• This was a beneficial experiment in that the Secretary of DHS both raised selected areas 
of the country and then the whole country to Red. In addition, local jurisdictions raised 
their own threat conditions to Red; 

• T2 revealed considerable confusion about the notification process and notification 
channels from the Federal Government to state and local governments. Local efforts to 
raise their own threat conditions produced confusion elsewhere in the country as to 
whether the statuses of the local conditions were DHS-driven actions. There was also 
ctmfusion at all levels of government about what actions should be taken at Red, 
particularly in the case of selected locations; and 

• Finally, although it was not fully explored during the exercise, concern was raised about 
the costs of being at Threat Condition Red — particularly in the absence of specific threat 
information. 

C. T2 involved an extraordinary sequence of two Stafford Act Declarations wrapped 
around a Public Health Emergency Declaration by the Secretary of Health and 
Human Services 


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T2 


• The Presidential declarations were for a major disaster in the Washington venue and an 
emergency in the Illinois venue. These two declarations illustrated some of the subtleties 
of the Stafford Act that may not have been fully appreciated before the exercise; for 
instance, a bioterrorism attack does not clearly fit the existing definition of disaster as 
defined by the Act. ; and 

• The Secretary of Department of Health and Human Services (HHS), acting on authorities 
through the Public Health Service Act and in consultation with the region, declared a 
Public Health Emergency. This permitted HHS to authorize the use of federal assets (with 
costs covered by HHS). It appeared to lead to some confusion about where authority to 
deploy certain assets really lay, with HHS or DHS. 

D. Planning and development of the National Incident Management System should take 
advantage of the T2 experience 

• This comment from the TOPOFF 2000 report bears repeating: "Multiple direction and 
control nodes, numerous liaisons, and an increasing nun^er of response teams 
complicated coordination, communications, and unity of effort.” If anything, T2 may 
have been characterized by even more teams and communication nodes; 

• Communication and coordination issues drove the course and outcome of critical public 
policy decisions from the elevation of the Threat Condition, to the various 
disaster/emergency declarations, the determination of exclusion zones, and the re- 
opening of transportation systems. To the extent that there were problems in these areas, 
communication issues were likely the primary cause; and 

• T2 showed that how people believe communications and coordination are supposed to 
work is often not how they work in practice. What may appear to be clearly defined 
processes — such as requesting the Strategic National Stockpile — in practice become 
much more difficult. The National Incident Management System process needs to 
leverage the T2 experience. 

E. T2 represented one of the largest hospital mass casualty exercises ever conducted, as 64 
hospitals in the greater Chicago area participated in response to the bioterrorism 
attacks, and 123 hospitals either received faxed patients or participated in the 
communications of the exercise 

• As such, T2 represented a significant experiment in communications and coordination for 
the public health and medical communities. In particular, the massive amounts of 
communication required to track resource status (e.g., beds, specialized spaces, medical 
equipmeni) taxed hospital staffs; 

• T2 did not last long enough to fully explore the impacts of mass casualties due to 
bioterrorism on the medical system. Much less than half of the infected population was 
visible to the medical system at the conclusion of the exercise. This remains an area to 
explore in future exercises; and 

• While there were a number of attempts to estimate the potential scope of the outbreak, the 
focus of most activities appeared to be on the cases that were presented to the health care 


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T2 


system. It should be noted that HHS was working actively as the week went on to 
identify the resources that would be required to deal with the infected population. 

F. In the Illinois venue, T2 play involved an extensive Strategic National Stockpile request 

and distribution component 

• Although the actual distribution process appeared to go quite well, there was some 
confusion over the procedures and processes for requesting and receiving the stockpile. 
The SNS Operations Center coordinated the stockpile deployment with the Centers for 
Disease Control and Prevention (CDC) and the FEMA EP&R Director; however, there is 
no data to indicate that senior-level consultation occurred between DHS and HHS. In 
addition different jurisdictions in Illinois took different routes (for example, through DHS 
FEMA and the CDC) to request the SNS; and 

• The Jurisdictions in the Illinois venue were forced to confront important decisions about 
how the stockpile (and local assets) would be divided and which population groups 
would be the first to receive prophylaxis. The discussions and decision-making involved, 
as well as the challenges of coordinating public information, provide valuable lessons to 
any metropolitan area. 

G. The Department of Homeland Security should consider integrating the existing 
response policies and plans into the National Response Plan 

• States are familiar with and have built their response plans to interact with federal assets 
using similar agency and department structures and language; 

• Federal agencies are satisfied with the language, authorities, and relationships outlined in 
existing plans such as the Federal Radiological Emergency Response Plan and the 
National Oil and Hazardous Substances Pollution Contingency Plan: and 

• As the National Response Plan continues to be developed, the surrounding issues merit 
consideration — particularly where existing plans are considered effective for emergency 
response. 

H. T2 involved more intense and sustained top official play than occurred during 
TOPOFF 2000 

• Of particular note was the play of DHS (which had been in existence for only a little 
more than ten weeks prior to the exercise), including the Secretary and other senior 
civilians: and 

• HHS operated the Secretary’s Command Center, non-stop, throughout the exercise with 
extensive play at the Assistant Secretary and Operating Division Director level. The 
Secretary was actively involved in T2 play, and since the Illinois venue involved 
substantial public health and medical play, the active participation of HHS was critical to 
the success of the exercise. 

• In both the Washington and Illinois venues, the offices of the mayors, county executives, 
and governors were well represented throughout the exercise by either the elected 
officials themselves or high-level policy-makers in respective administrations. In 
particular, the Mayor of Seattle participated substantially in the FSE, providing local top 


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leadership that greatly contributed to the realism of play and to a greater appreciation of 
the local challenges and perspectives in a national WMD attack. 

1. T2 represents a foundational experience to guide the future development of the 

TOPOFF exercise series 

• Because of the intense data collection process and the effort to make T2 findings 
traceable through a detailed reconstruction of the exercise events, T2 now represents a 
baseline upon which subsequent TOPOFF exercises can build and to which they can be 
rigorously compared. In addition, continued analyses of T2 data can be employed to help 
guide the design of the National Exercise Program. 

• T2 demonstrated the value of the international, private sector, and non-profit perspectives 
and roles in any response to WMD terrorism. Future exercises will, no doubt, expand on 
these elements by broadening the participation of these sectors. 

• The use of an opposing force (OPFOR), or red team, during T2 provided ground rules for 
the involvement of a simulated active enemy threat in future exercises. This play should 
also be expanded in future exercises, as it repre.sents one of the fundamentally different 
challenges responders face in a terrorist WMD disaster relative to any natural or 
conventional disaster; and 

• The success of the VNN, and widespread participant feedback regarding the desire for 
additional challenges in the area of public information, suggest that future exercises 
should include a more aggressive mock-media element, with a more aggressive news 
gathering function. 



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X. GLOSSARY OF ABBREVIATIONS AND ACRONYMS 


A 

AAC 

AAR 

ADLE 

ALS 

AMS 

AMTRAK 

ARAC 

ARC 

ASPHEP 

ATF 

B 

BEN 

BDC 

BLS 

BTS 

c 

CA 

CAN 

CAT 

CBP 

CBR 

CBRN 

CBRNE 

ecu 

CDC 
CDC EIS 
CDPH 
CDT 


After Action Conference 
After Action Report 
Advanced Distance Learning Exercise 
Advanced Life Support 
Aerial Measuring System 
National Railroad Passenger Corporation 
Atmospheric Release Advisory Capability 
American Red Cross 

Assistant Secretary Public Health Emergency^Pre 
Bureau of Alcohol, Tobacco, Firearms and Explosives 


Business Emergency Network 
Bomb Data Center (FBI) 

Basic Life suppent 

Border and Tran^onation Security (DHS) 


California 

Canada 

Crisis Action Team 

Customs and Border Protection (DHS) 

Chemical, Biological, Radiological 

Chemical, Biological, Radiological, Nuclear 

Chemical, Biological, Radiological, Nuclear, Explosive 

Hospital Critical Care Unit 

Centers for Disease Control and Prevention 

CDC Epidemic Intelligence Service 

Chicago Department of Public Health 

Central Daylight Time 



ness (HHS) 


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CEO 

CFR 

CIRG 

CMC 

CMG 

CMT 

CO 

COG 

CONPLAN 

COOP 

CPX 

CST 

CT/NP-ESG 

CYBEREX 

D 

DC 

D-Day 

DEST 

DFO 

DHS 

DHS CAT 
DHS CBP 
DHS EP&^ 
DHS'ICE 


A 


Chief Executive Officer 
Code of Federal Regulation 
Critical Incident Response Group (FBI) 

Crisis Management Center 
Consequence Management Group 
Crisis Management Team (Kane County, IL) 

Colorado 

Continuity of Government 

United States Government Interagency Domestic Terrorii 
Concept of Operations Plan 

Continuity of Operations Plans 

Command Post Exercise \ 

Civil Support Team (National Guard WMD -^^T^ 

Counter-Terrorism and National Preparedness 'Exercise Sub-Group 

Cyber Exercise 





District of Columbia 

D-Day (-/+) (T2^1I(S|^^!^xeJCise Start Date) 
Domestic Emergency Support Team 
Disaster Field Off^e (FEMA) 


Dep^ment^o^Iomeland Security 

DHS (Srisis Acrion Team 

DHS Bureau of Customs and Border Protection 


^DHS/^P 

DHS/OEI^ 

DHS/TSA 

DMAT 

DMORT 

DOD 

DOE 

DOE RAP 




DHS Emergency Preparedness and Response 
S Immigration and Customs Enforcement 
DHS Office for Domestic Preparedness 
DHS Office of Emergency Response 
DHS Transportation Security Agency 
Disaster Medical Assistance Team 
Disaster Mortuary Operational Response Team 
Department of Defense 
Department of Energy 
DOE Radiological Assistance Program 


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DOE AMS 
DOE ARAC 
DOE NNSA 
DOH 

DOH/DRP 

DOI 

DOJ 

DOL 

DOS 

DOS S/CT 
DOT 

DOT CMC 
DPH 
DSHL 
DTRA 

DTRA HPAC 


E 


DOE Aerial Measuring System 
DOE Atmospheric Release Advisory Capability 
DOE National Nuclear Security Administration 
Department of Health 

“Washington State Department of Health, Division of Radiation 
Protection Plan and Procedures for Responding to a Radiological 
Attack” 

Department of Interior 
Department of Justice 
Department of Labor 
Department of State 

DOS Office of the Coordinator for Count 
Department of Transportation 
DOT Crisis Management Center 
Department of Public Health 
Deputy State Health Li^ol^^ashington State) 

Defense Threat Reduction^^ency^^^ 

DTRA Hazard Prediction ana|Assessment Capability 





ED 

Emergency Department 

EDT 

Eastern Daylight Time 

EIS 

CDC Epidemic Intelligence Service 

EMnet 

Emergaicy Management Network 

EMS 

Emergency Medical Services 

EOC 

Emergency Operations Center 

EPA 

Environmental Protection Agency 

EPA RRC 

EPA Regional Response Center 

EPA RERT 

EPA Radiological Emergency Response Team 

EPl 

Emergency Public Information 

EP&R 

Emergency Preparedness and Response (DHS) 

EPR 

Emergency Preparedness and Response (DHS) 

ER 

Hospital Emergency Room 

ERT 

Emergency Response Team 


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T2 


ERT 

ESF 

ESMARN 

ESP 

EST 

EXPLAN 



FJIERP 
4FRMXC. 
FRP 
FSE 
FSL 

G 

GIS 

GLODO 




Evidence Response Team (FBI) 

Emergency Support Function 

Emergency Services Mutual Aid Radio Network 

Extranet Secure Portals 

FEMA Emergency Support Team 

Exercise Plan 


Federal Aviation Administration 
Federal Bureau of Investigation 
FBI Bomb Data Center 
FBI Critical Incident Response Group 
FBI Evidence Response Team 
FBI Hazardous Materials Response U 
FBI Hostage Rescue Team 
FBI Special- Agent in Charge 
Federal Coordinating 
Food and Drug iAdm inistratioS 
Functional Exerci^ 

Federal Emergency'Managemeni Agency 
FENl^ij&T^rgency^'^upport Team 

FEMA Nahoa^Interagency Emergency Operations Center 
For Official Use Only 
Federal Protective Service 
Federal Railroad Administration 

deral Radiological Emergency Response Plan 
Federal Radiological Monitoring and Assessment Center 
Federal Response Plan 
Full Scale Exercise 
Federal, State, & Local 


Geographic Information System 

Group for the Liberation of Orangeland & the Destruction of Others 


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GMT 

GSA 

H 

HAN 

HAM 

HAZMAT 

HDER 

HHS 

HHS ASPHEP 
HHS SERT 

HHS see 

HIPAA 

HMRU 

HPAe 

HQ 

HRT 

HSAS 

Hse 

HSeenter 

HSPD-3 

HSPD-5 


Greenwich Mean Time 
General Services Administration 


Health Alert Network 
Amateur Radio Operator 
Hazardous Material 

DOE/DOJ Homeland Defense Equipment Reuse program 
Health and Human Services 

HHS Assistant Secretary Public Health Emergency, Preparedness HHS 
HHS Secretary's Emergency Response Team . 

HHS Secretary's Command Center 

The Health Insurance Portability and Accountability .Act 

Hazardous Materials Response Unit (FBI) 

Hazardous Predicting Assessment Capabilities 

Headquarters 

Hostage Rescue Team (PBi) 

Homeland Security Advisory System 
Homeland Security Council 
Homeland Security Center (DHS) 

Homeland Security.Presidential Directive-3. 



"Honwla^^e^mty Advisory System ” 
Homeland Security Presidential Directive-5, 
“Management of Domestic Incidents" 
Department of Housing and Urban Development 


Interstate Highway 5/ Interstate Highway 90 
Interagency 

Information Analysis and Infrastructure Protection (DHS) 
Incident Commander 

Immigration and Customs Enforcement (DHS) 

Incident Command System 
Hospital Intensive Care Unit 


225 



T2AAR 


T2 


IDPH 

lEMA 

IL 

ILCS 

IL DOT 

IMERT 

ING 

lOHNO 

IPS 

ISO 

1ST 

lUSAR 

IV 

J 

JIC 

JOC 

JTF 

JTTF 


Illinois Department of Public Health 
Illinois Emergency Management Agency 
Illinois 

Illinois Compiled Statutes 
Illinois Department of Transportation 
Illinois Mobile Emergency Response Team 
Illinois National Guard 
Illinois Operational Headquarters and Notification OlTici 
Illinois Pharmaceutical Stockpile 
Incident Safety Officer 
Incident Support Team 
Illinois Urban Search and Rescue Teai 
Intravenous 


Joint Information Centa 
Joint Operations Center 
Joint Task Force (DOS) 
Joint Terrorism Task Force 



-r 



M 

MALS 


King^ounty, (Washington) 

King Sounty Charter, (Washington) 

King Cc^ty Office of Emergency Management 

Kane Local Emergency Radio Network (Kane County, IL) 


Lead Federal Agency 

Local Integration to access NARAC with Cities program 
Liaison Officer 
Large Scale Game 


Mobil Analytical Laboratory System 


226 



T2AAR 


T2 


MCC 

MCFR 

MCHC 

MD 

MERRT 

MERS 

MOA 

MOU 

MSEL 

N 

NARAC 

NASA 

NCP 

NCR 

NCR FE 

NDMS 

NIEOC 

NIMS 

NNSA 

NOAA 

NRC 

NRP 

NSC 

NSC PCC 
NSC PCC 

(CT/NP-ESG) 

NWS 

NY 

o 

ODP 

OEM 

OER 


T2 Exercise Master Control Cell 
Montgomery County (Maryland) Fire Rescue 
Metropolitan Chicago Healthcare Council 
Medical Doctor 

Medical Emergency Radiological Response Team (Veterans Affairs) 
Mobile Emergency Response System (National Guard) 
Memorandum of Agreement 

Memorandum of Understanding ik 

Master Scenario Events List ■ ^ 




hiliiy ^ 




National Atmospheric Release Advisory Cilapabitoy 
National Aeronautics and Space Adminw^tit^ 

National Oil & Hazardous Substances PollutidivContingency Plan 

National Capital Region 

National Capital Region, Functional Exercise 
National Disaster Medical System 
National Interagency Emergency Operations Center 
National Incident Management System 
National Nuclear Security Administration 
Natiwial Oceanic and Atmospheric Administration 
Nuclear Regulatory Commission 
National Response Plan 
National Security Council 

National Security Council, Policy Coordinating Committee 
National Security Council, Policy Coordinating Committee, Counter 
Terrorism and National Preparedness Exercise Sub-Group 
National Weather service 
New York 


Office for Domestic Preparedness 
Office of Emergency Management 
Office of Emergency Response (DHS) 


227 



T2AAR 


ONCRC 

OPFOR 

OSHA 


Office of National Capital Region Coordination 
Opposing Force - Opposition Force 
Occupational Safety and Health Administration 


PDD-39 


PHSKC 


POD Hospital 


PROFLOW 

PRO-NET 


RCW 


RDD 

REOC 

RERT 


Public Address system 
Protective Action Guidelines 
Policy Coordinating Committee 
Polymerase Chain Reaction 
Presidential Decision Directive-39 
“US. Policy on Combating Terrorism" 
Pacific Daylight Time 
Phoenix Fire Department ' 

Principle Federal Official ^ 

Public Health Seattle/KingjCounty 
Public Information Officer w 
Point-of-Contact ' 






iCv 


Illinois Disaster POD Hospital. Term used by the IDPH disaster 
plan for hospitals designated to consolidate and coordinate regional 
hospital medical informatitm for further transmission to lOHNO. 

Personal Protective Equipment 

Procedural Flow Synopsis 

Professional Reporting Network {DuPage County) 


Radiological Assistance Program 
Revised Code of Washington 
Region Director (FEMA) 

Radiological Dispersion Device 
Regional Emergency Operations Center 
Radiological Emergency Response Team (EPA) 
Registered Nurse 

Regional Operations Center (FEMA) 


228 



T2AAR 


T2 


RMAC 

RRC 


Radiation Monitoring and Assessment Center (Washington State) 
Regional Response Center (EPA) 







Special-Agent in Charge (FBI) 

The Substance Abuse and Mental Health Services Administration 
Severe Acute Respiratory Syndrome 
Secretary’s Command Center (HHS) 

Same Day Surgery 
Seattle-Tacoma International Airport 
Senior Energy Official 

State of Illinois Emergency Operations Center 
Secretary’s Emergency Response Teai^(HHS 
Seattle Fire Department 
State Health Liaison (Washington State) 

Strategic Information and Operations Center 
The State Interagency Response Te&i?(Illinois) 

Subject Matter Expert 
Strategic National StoclqiUe 
Strategic National Stockpile Operations Center 
South of Downtown district of Seattle 
Seattle Police Department 
Science & Technology (DHS) 

Surface Transportation Board 


TOP OFRCIALS EXERCISE SERIES 
TOPOFF Pulmonary Syndrome 
TOPOFF 2 

TOPOFF 2 Full Scale Exercise 
TOPOFF 2 Large Scale Game 
Temporary Flight Restrictions 
TOPOFF Pulmonary Syndrome 
Transportation Security Agency 




229 



T2AAR 


T2 


TTX 

TV 

TX 

u 

US 

USAR 

USCG 

USDA 

uses 

UT 

UTC 

V 

VA 

VA MERRT 

VCC 

VMI 

VNN 

VTC 

W 

WA 

WA DOH 
WA DOT 
WDOT 
WHO 
WMD 


Table Top Exercise 

Television 

Texas 


United States 
Urban Search and Rescue 
United States Coast Guard 
United States Department of Agriculture 
United States Geological Survey 
Universal Time 
Coordinated Universal Time 


Department of Veterans Affairs 


VA Medical Emergencv'Radiological Response Team 


T2 Exercise Venue Contn^C^llI 
Vendor Managed Inventory 



Virtual News Network- 
Video Teleconference 


bjXell^ 



Washington 
Washington State Department of Health 
Washington Department of Transportation 
Washington Department of Transportation 
World Health Organization 
Weapons of Mass Destruction 


X-Y-Z 


230 



T2AAR 


T2 


TOP OFFICIALS (TOPOFF) 
EXERCISE SERIES: 



TOPOFF 2 (T2) 


After Action Report V 


ANNEX A 


September 30, 2003 


Information contained in this document is intended for the exclusive use of T2 Exercise Series 
participants. Material may not be reproduced, copied, or furnished to non-exercise personnel 
without written approval from the Exercise Directors. 





T2AAR 


T2 




TOPOFF 2 Electronic Reconstruction Product 


NOTE TO USERS: 

Background: This file provides an electronic, searchable reference of significant 
domestic (United States) events and decisions that occurred in the TOPOFF 2 (T2TFuIl 
Scale Exercise (FSE) between May 12-May 16. 2003. The events in this reconstruction 
took place in 3 venues: the State of Washington (WA), State of Illinois (IL), and 
Washington DC (referred to as the "Interagency," and abbreviated as "lA"). It was 
developed through the reconstruction process detailed in the T2 After Action Report 
(AAR) and distilled from more than 20.000 lines of raw data entered directly from data 
collector logs, controller records, participant and agency logs, situation reports, and 
emails. This file is NOT data. It reflects analysis and follow-iip work by analysts to 
deconfiict data within and between venues. Its purpose is as a reference to participating 
and non-participating entities to provide them a sense of the fiigniftcant events, activities, 
and decisions that were faced by the national response community in re.sponse to the 
events in the T2 FSE scenario- a perspective no single agency Could have on its own. 
This does not provide a detailed account of any particular agency's actions. 

Additional Notes: 

Note that all times reflect Eastern Daylight Time (BDT), which was the official exercise 
time. Original times have been converted in orderto provide an integrated and time- 
synchronized perspective. 

Note that the "Source" Column refers to the organization or organizations which 
submitted data to support Iheeveni/acrivity/decision listed. There may have been 
additional organizations Ih^ documented any given event/activity/decision. 

An Acronym list is provided for the entire Reconstruction as well as for references 
specific to each venue. 

■V 

^^1 events/activitiea/decisions are associated with the venue of their occurrence in the 
■' '‘Venue" column. 

The Reconstruction ends with the last evenl/activity of significance in the FSE at 204 
hours on 15 May. 


7/17/2007 922 AM 


lA i2May-03 



WA 12-May03 

lA 12-May03 


[L 12-May03 


f^UECT; The DEST departs Andrews Air Force Ease in response to a creA*e ttweal adainst the Columbia 
GonerelinQ Station tn Richiand, WA. (MS£L < 3042) 


At 1 1 ;5d Vihual Mews Network (VNN) begins coverage at an explosion in the South of Downtown (SOOO) 
District in Seattle. WA. 


iL SEOC reports that There has &eer> a reported eiplosion in Searile. At iNs p6nt. ti is not certain what the 
cause of the explosion was. A^ncy iaisons to be contacted to report to the I. $EOC. Advised to mlity 
I EM A Director. 


Upon waiehing the initial VNN report, FEMA Regton X Regional Operations Center (ROC) Deector noticed 
Emergency Support Function (ESF) lead agencies and requested they send harsione to siafl the ROC 
(corresponds lo MSEL « 2052). 


SNS Operaoons Center activated 


Chicago OEMC elevates local alert level Irom YeHow to Orange 


Analyst Comment 
Event was nobonal so Hme is notional 


rirr« ranges from 1 1 Se tot 2 f»PDT (14:5$ to 15:03 
EOT). Time choosen was tiom WA VCC Offoal time and 
MSEL Team log. 


Time laken was Nom naia eol o clof 
tiir>e s were recorded at 14;02 and 
1 6n 0 EDT) by (he USEL team 
Action Mtiated from VNN report 
representatives aduatiy cametp 
betve STARTEX. k , 








WA 

12May-03 

15:03 

Cpon waicning Iha niSal VNN rapon. Saanie ECC noanaa the King County EOC ol an auRMon n the 

KDI <191M EDI) n^tK 




SOOO Distnet of ihe city (corresponds to MSEL # 2023), 

(15:10 EDT) fror^iwr 
PDTflSfO EC9rafto\ 
MSELs^Mdaneel. 1 


WA 12May'03 


IL 12-May03 


WA 12 May 03 


WA 12Mtiy03 


Based on VNN report. Seaille FBI Field Oflic* Operations Coorttinafor noefiee SIOC {corresponds to MSEL « 
201 ?) 


IL SEOC activated 


After watching the mibal VNN repon. me Seenie EOC nooAes Washmgion Swe Ferry 
explosion in the 5000 Distnct of Ihe city. They a ckn owledge ihai they are aware 
activated their EOC (corresponds to MSEL » 201 5). 


Time was chosen from 
EOC.SfOCOPSC 
the same time 




Data CoUacior Log 


Data CoHaolo' Log 


Saattia EOC: KC 
EOC: WA Sta» 
EOC 


WA Staia EOC 


IL Stata EOC 



STARTEX Ai 12:08 an a.pKia>onoccuraaitntlolataaciicaiol Ml Ava Sand SoutAHankM 
2005). 


S'. 


Tune used was obtained from WSF Lead Controller at 
WSFEOC. Other times were 12'0$PDT(l5f)e EOT) from 
a Seaffla EOC DC and 12:10 POT(1S :10 EDT) from the 
Team (irtiM|»n source). 


by VCC Drector lor 10 minutes 
due to placement of victims. Time laken wes from WA 
VCC Official Urrw. analyst on ele at ROO and M8EL Teem 
log OVtoT repMed timee ranged from 12:08 to 12:10 POT 
to 15:10 EOT). 


INJECT; Seatile Police and Fire (tispatch simulaie getting 91 1 calls 
WA l2*MBy*03 15:09 reeportd and mveettgate. Based on the sinHjiaied cal vob/ne and 

apprcpriaie responsa (MSEL f 200$), 


1 2*Msy03 15:10 Seattle EOC Drector begirds the EOCt notiftoalton chams (corresponds 




MSEL Team: Analyst Log 




Time taken from SealUe EOC DC log. 


petid cars. Ai ol wormaiion leken from severel DC tog entries mal occur 
Iht eiplwon (eon^pond* ,2^ gm, ,3 „ p[>T(i5« and 1S:<5E0T), 


12-MaH3 18:10 


Put>>« Haann-SfattlaSKing County IRIWC) E 
EOC cf the explosion (corresponds to liKL i 201$ 


No data points suggest that PK8KC EOC was notthed by 
noencallanb«ih.S«nlln Mcapal Cenba »» »ss ca»M (or in the MSEL. An2.l0 
nooncaianoymaMOTa P0T(1S:10£DT) SMIla EOC notiried PH8KC EOC. AI 
12.28 POT <1525 EOT) (ho mcidenl cnmmandBr nolifiad 
PHSKCEOCuwet. 


Dait CsHdclor Log 


Data Coiiaciar Loga 


Data CoHador Log 


RDO ana: KC EOC: 
Hartorviaw EOC 



12Mey-03 

1 

15:10 WA SEOC notified of the explosion and adiv^d to Phase III (corresponds to MSEL * 2025) 

Time nows when WA SEOC was notthed. not by «mom 
(MSEL caned for (he WA SEOC to be notified by the 

Seatile EOC). Time as taken hom data collector at WA 
SEOC. Other timee cotoctod by the MSEL team were 

1 2:1 1 bid 12:30 POT (f 5:1 1 and 1 5:30 EOT). 

Data Collector Log, MSEL Team 

WA State EOC 

12May-03 

'L 

1 5:1 FEMA Region fOpformed that The WA SEOC is acUvaled (corresponds to MSEL * 2039) 

Tima taken was Irom OC m WA SEOC. WA SEOC made 
caH based on VNN report, not actual detonation. Other 
limes laponed were 12.36 by the MSEL team and 12.00 by 
the FEMA VCC Rep. 

EOC Supervisor Log: MSEL Team 

WA State EOC 


Message sent Command Center (SCC) to COOP Nofifkalion, throu^ Roam Saoee 

15:11 Alert Network: Ajtirgeei^iMininthe SOOO Distnet of Seattle. WA. unknowr) source o< ex(4osioo. imknown 

injuries. ^ ' 


Agency Log 

DHS/NS Center 


^16*12 SFDannouncedft^Mctimswhocanwalk should slowly approach Engine those who need help are 
^ instructed to stafjihere they are 

Annoimmert starred at 12:12 PDT(1S:12 EOT) and was 
continuous to at least 12:1$ PDT (15:18 EDT), 

Data CoKacbr Log 

ROD site 





12-May-03 '< 
12May-03 15^ 

i2May-03 15:12 


Seattle EOC activated b Phase III operations 

. '• Washington Slate Emergency Management Division (WA EMD) Director cals the WA SEOC aftti orders a 
(Full Operations} activation. 

Region to On Scene Coordinator deployed b incident site 


Seattle EOC Log 
Data Collector Log 
Data CoKecbr Log 


Seattle EOC 
WA State EOC 
EPS Aux. OpsOir 


T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reconstruction 


Page 1 of 29 






FO R OFRC I AL U SE ONLY 

DRAFT 


7/17/2007 922AM 


Venu& 

Date 

Tima 

rFDT^ 

Description 

Analyst Comment 

Typxtam 

Source 

OmanuatifMi 

IL 

12Mdy-03 

15:14 

CPD noirfieO (he following depanments and aoeneies about (he explosion in Seattle: 


Data Cdiecsor Log 

Chicago EOC 

n. 

12May-03 

15:15 

Chicago EOC AcTivated 


Data Collector U>g 

Spnngfleld IL EOC 

lA 

1 2May-03 

15:15 

Repon to SIOC That Ihe FBI SAC has been nooTied. (he ERT and SWAT recalled, and afi on-scene 
commands dispatched 


OPS Cooidinatof Component Log 

SI(DC 

lA 

12-May-03 

15^0 

FEMA EOC receives cal from FEMA Repion X ROC reporting a bomb blast m Seane 


OPS Coordinator Component Log^ 

FEMA EOC 

WA 

12-May-03 

1551 

Based on the report from (he City of Seattle Emergency OperaSon Center regarding a Ivge explosion h the 
vicirMy ot 2700 Airport Way. Ihe King County Emergency Operation Center (EOC) has been KOvaied at 

Level ill. The cause ol explosion is unknown; no other detals are avaiable at (h>s (line. 


MdamMsass 

KC 1C 

WA 

l2May-03 

1552 

IfiJECT: Seatiie Fite Oepartmerx Unil 77 (HAZMAT) simUated respwidng from Slaaon 2 (SFD HO). This 
would have brought (hem Ihrough (he plume, so as they were reapondmo controlers irdormed players that 
mere radtaton pagers alarmed {MSEL # 2013). 

riire came from rue Alarm Cante^call logi^Unit 77 
(HA2MAT) Hrvnadiaiely calad in thare raQiaiion 

pagat alarmed. Data CaHeaorlogahadlhe erne allSM 
POT(15a9 EOT) trom IfieKC EOC. 12 22 PDT{15 22) 

EOT from radto datfic^rhaard arm ROD Sita, and 

1t21 POT (1521 EOTjaem tt* SFO FAC. 

Data Colleclor Logs 

KC EOC; ROD Site; 
SFD FAC 

WA 

12-May-03 

1525 

A traige station is beino set up near Ladder 7 and mulb casually urMs. 150 ytds south ot bomb site 

Time Idien nwfrom RDD DeoOQ 

CorJroSor On>y dear data about Tnage. 

Daia CoJiecior Log 

RDO site 

lA 

12'Me7-03 

1555 

SiOC r«ceiv«s r«port Irom OHS lhal raMlion wu MscM m SaaBla 


Oaia Conaclo. Log 

FBI SIOC 

lA 

12-May'03 

1555 

VNN update: unconlirmed report ot deiectkm ot radwion 


Data ColleetorLcg 

COCEOC Atlanta 

WA 

12 May 03 

15:29 

At 1230 the city of SeaRle lead PIO authorizes a press releasa acknowledging (he 
activation ol the EOC and response ol the city's irst responders to an expioeion 

Text 

FOR IMU EDIATE RELEASE 1 290. 1 2 May 20» 

SUBJECT : FOR MORE INFORMATION GOffTACt 

Seane EOC Acuvaied City of SeaUe EOC Media Line : (206) 2^3 5072 

ht^y/wmv seane gov 

City ol Seeltle Acliveles Emergency Operetons Center lo 
respond tc emergency eoulh of downtown Seeltle 

The Seeltle Poliee Chhel activaied the City ot Seelde's emorgotxy operabons 
earner just past noon today In response lo an explo»on south of duaiiMni Seme 

Polce and Fire personnel ere on scene lo determme (he naiure of liWast. 

Cltlzans ara urged lo avoid the area within e mile of Airport Way S. ehBB. Hnda ^jent 

The Seeltle Mayor la being brieled and wSl address the pubkc as soon ^poeMbie 


Press Reiesse 

Seanie EOC 

WA 

12May03 

15:30 

Washington Stale Top OfliciMs n m^A SEOC Policy Room alert ihe Wa«Wtglon Slate Nabonel Guard 

WMO Civil Support Tsam to go On pf^pa^ (0 deploy si sunxxtBEthe CFy of Seattle 


SOC Si^Mrvisor Log 

WA State EOC 

WA 

12May-03 

15:30 

FBI SAC oobfied Ihel radiation was dete«||d al die laetdem sHe. The SAC requested the OEST vid HMRU 
and rsquested that the SIOC be notHied ftnnn ruMjlTlri USEl aWBI 

Time taken was Irom FBI SAC Log. but where the 
notificeeon c«ne from » not noted (MSEL caked for 
nolHicetion to come from the Sestde EOC). Other time 

1 2 35 POT {t $.3$ EOT) from M$EL Teem • source 
unkrmm 

SAC Log Oats: MSEL Tasm 

FBI WA Field Olfiee 

WA 

1 2May03 

• 15:32 

A 

The WesningtoHCteie Ferry EOC locked down all ferned and shut down service (corresponds to MSEL # 
2026). 

Time was taken from WA SEOC data coi lector observing 
WSP Eaitesl time reported that Femes were shut down. 
Thw entry was recorded later, but specHicaly menpons 

12.32 POT (15:32 EOT) as shut down bme. Other entries 
merely not Ome cai was received or are time update was 
gnmn. not bme femes were shut down. Other reported 
times -1355 POT (1656 EOT) from a DC el the KC EOC, 
MSEL team ernes 1234 POT (15.34 EOT) reported to the 
MSEL learn from an unknown source, and 12:40 POT 
(15:40 EOT) reported to the MSEL team from the 

Lead ConircHer. 

Data Collector Log; MSEL Team 

KC EOC 


T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reconsiniciien 


DRAFT 

FO R OFFIC I AL USE O N LV 


Page 2 el 29 








FO R OFFIC I AL U SE ONLY 

DRAFT 


7/17/2007 922 AM 


Venue 

Date 

lEDTl 

Time 

lEDD 

Description 

Analyst Comment 

Type al Beta 

Source 

Oroanizetlon 

WA 

12-MayC3 

16:32 

INJECT: The detection o1 cesium was iniecied to ihe Incident Commander. The MSEL Mem represented was 
the time that lha FSl thought they would dated 1. The IC coniroler saw the bme come and pass and mfoaod 
this infonnation without permission from the VCC. Other ames recorded lor this occurwtg were 13:30 and 

1 4:1 5. captured by MSEL team, source unknown |MSEL # 2031 ). 

The detection of cesum was iniected lo the locfdeni 
Convnander The MSEL ffem represented was the bme 
that the FBI thought they would detect IL The IC controller ^ 
saw the bme come and pass and miecteO this mlormabon 
without permisaiori from Ihe VCC. Other limes recorded 
tor tNsoccuring were 13:30 and 14:16 PDT(15.'30 and 

1 7;I5 EDT), captured by MSEL team, source unknown. 

MSEL Team 

WAVee 

IL 

i2May-03 

15:33 

DuPage County EOC notiliea IL SEOC of explosion in Seaffie: moMng to Mbate EMNet (saiettte based poM- 
To-polm secure commumcaiiofts networti ol al EDO's) 


PfiMlWxvLog 

•fe 

DuPage Co. EOC 

IL 

12Mfiy-03 

15:35 

lEMA notified CCSEIM about an explosion in Seattle win poseble deiection o< radiation. Also nobfied that 
lEMA has opened ris EOC 


Message & Event Log 

CCSEMA 

lA 

12May-03 

15;3S 

INJECT. HNS see notifies HHS SERT o1 the mcidenl in Seattle (MSEL « 3106) 


Daia Colleelor Log 

FDAE(X 

IL 

^Z-UayOZ 

1625 

CNcaeo EOC holds Radoaclivo Disced Oovem <RDOs) consoquanco bnalnq 


Data CoHaciw Log 

Chicago EOC 

WA 

12-May'03 

15:36 

Tius is the bme in the MSEL lhal SFD HazMat ai4f0r SPD Arsorveomb Squad was to racerva radabon aiens 
on Their monbying devices There are no dear obeeivaikma kvn data coMociors. Many report HAZMAT or 
ABS ehowK>g up on scene and some ol iheir aelMies. but there are no dear descripdons o( them confirming 
the radiation rsadings {corresponds 10 MSEL • 2024). 


MSEL Team 

WAvee 

lA 

12^6^-03 

1SJ7 

Message sent by HHS SCC to COOP Noohcalion, through Roam Secure Alert NeMork: Rediabon has been 
detected in the expioaron In the $000 DWnct of Seattle Unknown ridioiogicaf type and level 


AganerLog 

DHS/HS Canter 

WA 

12-l^y03 

15:36 

WA EMD Director approves lha Arsi press reiase acKnowiedgHig m event m the City of Sdtfle and 
describing WA Stale's current response to tt>e silualon. . j 

Press Release: CAMP MURRAY, WA- The Siais Cmergsr>cy Oparabons Cenier (EOC) al Carnp Murray 
setivatsd at 12:10 p.m, today in respoosa to an explosion m ihe south. The WA QowimoriVB been infnmwf 
of the mcideni. Reprsseniattves from the scale depanmems of UiMary (Emergency ManagMiMU. Heahn. 
Transponabcn: Ecology: Agnculture: and the State Patrol as wel as the American Red Cross are reporting lo 
the State EOC. 

Press lelease was from DC notes, may not be exact 
wo'dmg, 

Daia CoUaciorLog 

WA Siaia EOC 

WA 

12-May03 

15:40 

Dseoniamlnahon area being established al irrcKlant siie 


Data CollaetorLog 

RDO she 

WA 

12Mfiy03 

15:40 

WA Governor has been kiformed of ihe knodant. 


Press Raisase 

WA State EOC 

lA 

12Mfiy'03 

15:40 

COC EOC Emergency Response Coordmaior prepares message lofiolPyCOC^flaWfs. msMuies 5 offices 
of The radiological ino4ant In Seanie '* 


Oala Coiieetor Log 

CDCEOC Allanta 

lA 

1i.kMy.C3 

16:A0 

FDA r«c«lv*s pTion* CM licm HHS SCC confirniing ladwon ot unkm«»<auM*<h SmiM 


Daia CgiMoor Log 

FDA. EOC 
Rockville, MD 

WA 

12-May03 

15:41 

King County EOC posts nolHicalion that security level is RED 


Daia CsllaclorLog 

KC EOC 

IL 

12-k4ky.C3 

iS’Oi 

Chiueo EOC noliliw BOkM. S«ars. Aon Canur. HancocA Bu4d^ regaidltBjQIBniial lanonsi iniaal 


Daia Collaclo'Log 

Chicago EOC 

lA 

l2Mav03 

15:42 

FDA EOC activated 


Oala CoUaciorLog 

FOA, EOC 
Rockville, MD 

lA 

l2.May.C3 

16:42 

TSA desk at DOT CMC recerves phone ctf from TBA 'eprosenlaflsv^DHS confirming rediabon ei SearOe 


Daia CiXiaeior Log 

DOT CMC 

lA 

i2.kMy.C3 

16:44 

VACO receives conTirrnatioci Irom DHS thatWMIion haa baen dateciad in Saatde 


Data CollaoiDr Log 

VA Central Office 

IL 

12-May-03 

15:45 

ChioagoDPH reports HAN is looking tor unusiA disease efusTers 


Daia Colleelor Log 

Chicago DPH 

(L 

12May03 

16.45 

F 

CPD leels uwlen attach by tenons) group “GLfVO* is imminent: hnlong a) nudeai targets. Chkago is at a 
'huighiened MR' status, increasing awareness and vigilance al possbie targets 


SEOC Event Log 

IL Stale EOC 

lA 

1i-May43 

1iS0 

Reports coming^ to HHS S<S^ frorn DHS about Pu 22$. Ce 137. and Amerioum 

Wtvie ths dto occur in the exemoe, there is no way That 
(he three lacfioacbve comporwnts could have been 
identified this early m (he exercise, HHS hasons in WA 
diecoiaited ttts informabon and 4 cbd not impact play. 

Daia Collector Log 

HHS 

WA 

t2-MaH)3 

15:51 

No chemical agens deawd at the incident see 

Actual time was between t2:6i vid 12:6$ POT (I6^t and 
16:59 EOT) 

Daia Collector Log 

RDD sirs 

lA 

12 May<M 

15 57 

HHS aanding SEFTT <6 Ragion X REOC 


Data Conaclor Log 

HHS 

lA 

i2.kMy.03 

16ST 

Region X REOC officially activated 


Data Conaclor Log 

HHS 

lA 

12-May-03 

15.57 

HHS raoeives request from DHS to Ktoniity HHS assets lhal are available to deploy - need tor brief to OHS 
Secretary 


Data Colidctor Log 

HHS 


T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reccnsirveti&n 


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Venue 

Date 

<€DT1 

Time 

fCOD 

Description 

Aftolyst Comment 

TypawtPattt 

Source 

OroanizaUon 

WA 

t2-May-03 

15:59 

Hospdal Control contacting all western WA ho^itals wtUi exception of Monroe County 


Oaia CcHfecfor Log 

Harbwview EOC 

WA 

l2May-03 

16:00 

SFD ftcMses SPO to sei up a command post next to SFD command post tor communcaaon purposes. SPD 
Incident CornmanOer directs arming SPO personnel to set up perimeter 


Data Coliactor Log^ 

RDO sits 

WA 

12*May 03 

16:00 

At 13:00 FEMA ROC Reg«o X received notification toal tfie Consequence Uangenemt Group at the JOC 
was stood up. 


Oala Coliactor Log 

FEMA Region X 
ROC 

lA 

12May-03 

16K)0 

INJECT: DOS task loree stands up m response to Ihe explosion In Seattle (MS€L *4040) 


Dale CoMetei Log 

HHS 

lA 

12-May'03 

16:00 

HHS see requests that CDC assernUe team of SMEs iha can potemaHy deploy to Seattle (corresponds to 
MSEL»3H1) 

■ 

MaCoKeenrLog 

CDC EOC Atlanta 

IL 

12May-03 

16KI1 

Chicago EOC receives information from Chicago DPH that Ihe HSAS has been elevated to RED. CMeago 
EOC holds at ORANQ€ until ths nlormaDon can be conAnned. 


SE(X Event Log 

IL State E(X 

WA 

12-May03 

16:02 

FEMA Liaison rsports that OKS Secretary dispaKhed a Forward Cco*dinaling Team to assiM the (C with 
determining resource needs. 


Agency Log 

WA State EOC 

lA 

12-May-03 

16:02 

DHS CAT SIMatJon Rapofi cenuma ucOala ffial GieaWi Saaltla B Laval RED 


SiluaKn Report 

DHS-CAT 

WA 

12-May03 

16:03 

SFD receives plume predtelcn from NARAC showing cloud moving N x NW (corresponds to MSEL f 2036) 


MSEL 

MSEL 

WA 

12-Ma/-C3 

16:04 

Law Team preparing Mayorat Proclamaiion of CMI Emergervy Order Dilegolk>n of Authority. This was dorte 
m consultation with Mayor's general cowrvei 


Agency Log 

WA State 
EOC/Seettle EOC 

]L 

12-May 03 

16:05 

Chicago EOC contacted METRA. RTA. and CTA and briefed them on toe situaiion: 'seH eocuaiicn 
locomotives bach in town; decide lo have CTA start ‘Rush Hour* earber 


Oaia CoHeaorLog 

Chicago SOC 

WA 

12'May'03 

16:05 

WA SEOC pohey group ashed siad to slan on Governor's proclamation 


EOC Supervisor Log 

WA Stale EOC 

WA 

12'May03 

16:05 

Air Space cloeura had been rsquosiad by 1C and Ihe WA SEOC. S mile rathus a/id up to lOOO leet 


Agency Log 

WA Slate 
EOC/Seanie EOC 

lA 

12-Mt7-«3 

16:06 

INJECT: F8l SlOC lo Issue warning ordsr lo Cnsts Medcto Response Asset (corresponds to MSEL 1 3673) 


Dale CollecldrLog 

FBI SlOC 

WA 

U-May-OS 

16:06 

Discussion at IC ensues about the NARAC model which leads to a raeommendai^ to sal ito a 10 ir^ grot 
where eltlaans should remain itt doors. They can raoommarid thrs bul ^ra rs nol ggough rnanpowar to 
enforce n. 


Daia CoHeetorLog 

RDO Site 

WA 

12-M>v«3 

16:07 

WA SEOC ooHcy group ashed siatl to start on raquesl tor a prawdansat dteister declarator!. 


Dal* CoKeclorLog 

WA State EOC 

lA 

12May03 

16:08 

FAA tepom 10 DOT Ctiwl ol Stall: T^mpmufy FligM RasmcMn (TFR) has ban lD> 30 nia radus 

arourx) SEATAC aroon ar traffic conffB' WaiBr up la 20.00011 All B bound Ui<K.1>aa baan ravlncWd 


Data Coiiacior Log 

DOT CMC 

WA 

12-May-03 

16:09 

King County Eaecutwe instructs EOC SM to notify County smpiopyats working in Seanit • M them to 

shelter in place, but prepare for them to niive 


Data ColleelorLog 

KC EOC 

IL 

12-Ma7-03 

16:10 

Chicago EOC chsplaving ShalMr-livPiaca acvftes in Sealtle: enacted vehicle pailang prohMon near taiget 
areas m and around Chicago 


Data CollatdorLog 

Chicago EOC 

lA 

12-May-03 

16:10^ 

ICE S>&iBMn Room end ICE HQ Reporting Cei^araeti rated. 


Situation Report 

DHS-CAT 

lA 


16n0 

CDC NCEH conanss the Prof mnary Assessment Tewn (PAT) to decuss the fesholOQica) averM. The PAT 
agrees lo aclivail| lha EOC - meaning response operations and associated support wfl canter in (he EOC. 
Additionally, tbe-RAT discusstd lha potential radtologcal elements batig report^-PlutonHsn 238^39. 

Cesium 137 and Americium Most of (he drecuesion tocusee on toe [exercise] "vahdify* of toe elements 
reported to have^en detoclad, giver> The detectors avaSable on*scene at Ihe Qme. CDOs lead lor radrabon 
indicated lha onydeiecttwwto vices ol a portable nature detect gamma amissions and toeretore woiid not ba 
able to detect thqsc alVffhts. CDC staff also alerted to be prepared to dqiloy to Seattle to siaiport FRMAC 


Data Coilecior Log 

CDC EOC Allanta 

m 

12 May 09 

1$ 14 

Seattle EOC PiQa issue press releases m mutt-languagee 


Agency Log 

Seattle EOC 

lA 

12-May-C3 

16:15 

EPA Auxiliary Operations Canter racarves raponihatradioacltve matanate have been defected in fiaU at 
Sealtle 


Dale Colleotor Log 

EPS Aux. OpsClr 

IL 

12-Ha»-03 

16:17 

IDPH advises Chicago OEUC ol change In alert slams tnxn Orange to Red: but nol conArmed. 


Data Coilecior Log 

Chicago EOC 


T2 /lAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reconsin>cii<>n 


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7/17/2007 922 AM 


Venue 

Date 

/EDTl 

Time 

rEDT^ 

Description 

Analyst Comment 

Type al Bata 

Source 

Omeniaatinn 

WA 

12Mdy-03 

16:17 

Sealtle OOT infomied $PO ot thee recommendation to hal al ffaffic coming rno downtown. They are 
developing a iraflfc plan. 


Seanie EOC Log 

Seanie EOC 

IL 

12Mdy-03 

1620 

ARC of Oreater Chtcago received message lhal radiologicdl aciiwiy delected in SeatOe 


Data CoKeetor Log 

ARC of Greater 
Chicago HO 

lA 

12May-03 

1620 

FEMA EST receives reQuesT lor 3 WWD task forces from E^-9 


Data Collector Log 

F94A EST 

lA 

12-May03 

1620 

fiAWAS earned a message lhal the NCR had gone to RED. 

The NCR had not gwie to RED at this time 

0^ CoHaclo. Ug 

HHS 

lA 

12May-03 

1626 

HHS EOC inquiring as to soiree of Seattle weather data (e g.. wind drecSon). COC radiation dMsion is 
working on short / long term effects of the radabon release and wll gel Mormason to hospitals on ttte 
eotopes 


OMfeenei^i.«g 

HHS 

lA 

12May-03 

1628 

DHS NS Cer^r received call from 0 SL 6 C Homeland Operaoons Camar saying that die Federal Protection 
Services reported that the Crty of Seattle raised Ihreal level lo Red 


HSC 0 SL 6 C Inckjem Log 

DHS/HS Center 

WA 

12May-03 

1629 

Update on WA DOT Road Closuras: I'S at M05 north bourtd (Tulnnlai at at 1-405 soundbound 
(Lynnwood}, thus f S ts closed down. 1-90 and SR S 20 are closed west bound imo itw City of SealBe. and the 
west bound lanes have been opened to Emergency routes east bound from the oiy of SMWe. Watfimgton 
State Ferry EOC has shut down all routes end Ferry operations 


lAP Section Activtty Log 

WA Slate EOC 

WA 

12-May03 

1624 

SPD SWAT and SPD EOD egrae lo ink up together before either go Mo target area 


Data CMleelor Log 

RDO site 

lA 

1 :-May 03 

18:34 

FBI SiOC and DHS are conaidartng redeptoymant of DEST 


D«la CdWcior Log 

FBI SIOC 

IL 

1:-Mey.03 

18.38 

ARC Of Grtato Cnicago racaii/M notHicanon (rom cntcago OEUC mai awn ataiua nmi to RM 


Dait ColWcio> Log 

ARC of Greater 
Chicago HO 

IL 

13'May.03 

18.35 

Diracio' o' Chica«a OEUC aOviMS nai cnanga io Rad « unccnfitniKi: hdd al Qrang^iailii HSAS noir^c-i'on 


Daw CoiWeior Log 

Chicago EOC 

WA 

i;-May-03 

18.35 

FBI ASAC. DEST assets redeployad, Ce137 identified. TSA closed airpqas s^irapaee. upcoottg press 
conference-nol releasing anything of substance^oo wdao 


Andyct log 

FBI Command 
Group Mig 

lA 

13-MaV'Q3 

1835 

INJECT: At iha request Of the Seattle SAC the SIOC requests DHS redeect ifM DEST to Seams from the 
Cotumbia Generating Station m Hanlo^ WA. 


TSA Daily Watcli Log 

OHS/CAT 

WA 

12-Mav-03 

16:36 

DOE Region 8 RAP Team recewee caH reqi 0 t>ng ass«tance from WA OCR (conesponds lo M$EL • 2037) 

Tima taken is from 0O€ RAP review comments. Other 
bmes recorded are from a WA SEOC data collector al 

1 3.66 POT { 1 6.66 EDT) . Of her times reported to the M$EL 
team are 1320 and 1357 PDT(I61» and 1657 EOT] 
from unknown sources. 

AAR Review Comments 

DOE RAP 

lA 

12May-03 

1626^ 

OOT CMC update: Washmglon Slate Ferry syslB^tfiut down, FHWA reports I'S is doeedL 1*90 is dosed 
wes'bound /open eastbound near blast site. 


Oala CMieetor Log 

DOT CMC 

lA 

12-May-03 

16 37 

DHS hat acUvaad NOMS 


Data CMlsctor Log 

HHS 

lA 

12-M|>03 

16.37 

DHS mmitis ssaitslorwaid.Ai Wen:4 DMATs. NMftT-C. Region 10 DMORT. OPMU wam. MST. OMORT 
WMD, IMSURT. * 


Data Collaclor Log 

HHS 

lA 

12<US9^ 

16:37 

HHS see notedpiat a ya there had been no Federal dedarabon-hence. OER advisad agamst actrvabon 
ofESFe 


Oala Collector Log 

HHS 

Ml 

l2*May*03 

1629 

SPD mobile convnand van now colocated with SFO mobile command van sid SFD ICP 


Data Collector Log 

RDO Site 

lA 

12May03 

16A0 

S40C reived report: Estimated 26 dead in Seattle blast area; Mast ?one is 


Data CoJlecfor Log 

FBI SIOC 


T 2 AAR Annex A - T 2 MASTER RECONSTRUCTION 
T2 Reccnsirveti&n 


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7/17/2007 922AM 


Venu& 

Date 

IfiDT) 

Tima 

lEDT^ 

Description 

Analyst Comment 

Type al Oats 

Bource 

Omanizattim 

lA 

12May-03 

17:10 

EPA OSC 'epon to EPA HQ: EPA respondais to start perimeier morvtoring; also sug^e^ moniioring and 
tracking of l si responders. 


Data C^dkectOf Log 

EPA EOC HQ D C. 

lA 

i2May-03 

17:10 

NCEH is notified lhal FEMA Region X ROC had become operalional as of 1 lOO EDT. 


Data Collector Log 

CO^EOC AUanto 

U. 

12-May-03 

17:11 

Chtcago EOC dsUtKAes mlormalion lhal HSAS level « stil ORANGE 


SBBCollBcIcrtDg 

ARC * Chicago HQ 

lA 

12-May'03 

17:17 

FBJ SiOC reports radtoaciive pKima moving toward or near SeaTac Aepod from dowrttown Sealtla. 


Data Coilactor Log 

FBI SIOC 

lA 

12May-03 

17:19 

FBI update: 4 male suspects • one suspect n custody by Seattle Pohce Deparimem: 3 at large 


Data CoJlaeior Log 

FBI SIOC 

lA 

l2-Mar-03 

1720 

DHS Secretary receives lenar from WA Governor requesting release o1 pre<poaliiOAed equipmem pacSege 
(PEPI ir> Seaffle; letiar is forwarded to CAT. 


Agency Log 

DHS/NS Contor 

lA 

12'M|7'03 

17:21 

HHS sands blood dortalion coordirtalor lo tali lo VNN and recirty lha slory on need kr blootf 


Dan CoiUctor Log 

HHS 

WA 

12-I4ay03 

17:25 

AMS (Aerial Monttonng System) daploymenl order issued 


Data CotlaetorLog 

WA Slate EOC 

WA 

12May-03 

17:32 

WAAMnoKin Sui» Govonor d«cur«« a SiaM o< Enia.ganci/ In Watum Waarxgnton n raaponsa lo iha 
axploaion cn SealM (conesponds lo MSEL ( 2074). 

Tad: 

1. Gary LocKa, Govamorol lhaalalaof WasMngton. as a rasuH oi iho a^orcmcnticnadaiutfanand jnder 
Chapiors se.oe. 3t.S2, ano 43.M RCW. do haiaby pmciam lhal a Slit ot EmorgiFiCy o««lt m ma Wesiotr 
Wasnington, and diract tha supponlng plana and procaduras lo lha WaMngloiLOliila CoiT^ehaoiiva 
Emaigancy Uanagamani Plan Pt nipiainaniad i also haraby onMf Mo^iwa siaia aaiviea ihtWaahmgkin 
Nahonal Guard. 1 do haraby aulhorUa lha Washinglon Emargaooy ManaynanI Division lo aaiiMsh Food 
Comroi Areas around lha araas lhal may ba contaminaM abova prolocovKanon guidaiinaa Tha 

Washrtgton Siaia Daparlniams ot RMRI and Agricuaura are aulhonsed loyssue food anibargoas lor lha 

Food CorHrol Ataa 10 rodua lha poaafillliiol aduUuralad lood lorm laaving vidEoiidConlrol Araa Uw 

Time taken was tram WA State EOC Log. Additional itmes 
Htoiude 14:22 POT (17:22 EOT) horn State EOCs EMACS 
Section log. t4;40and 15X10 POT (17:40 and 16.00 EDT) 
from MSEL Team logs 

Proclamation 

WA State EOC 




enforcement agenciea are authorued^ attpLaadicapect vehicles departng iaidantrhed Food Control Area 
and to direct the vehicle operators to food produced cr grown to es poiflHH origin w«iin (he Food Conlro 




WA 

12-Mav03 

1734 

DOH Rapraunialrre al WA SEOC malcBJ; raguast cUaci to FEMA lor FRMAC leam 


Daia CollaclorLog 

WA Siat« EOC 

lA 

1 2May 03 

17:35 

0H$-CAT sttuaoon update report FPS deflttii^ ROC. 30C. ^ aH maior federal locations in SeaOe 

FPS San Francisco 9 ready to send eddilMfitf cxAce ofhcera to seatHe. Pofece officers were deploying with 
radiation detection devices lo laciHlies nonm^l of the blasi she and Iraelung prevaiing winds 


Situation Report 

DHS-CAT 

IL 

12-Ha7-03 

17:36 - 

J 

Kaua Cnuiny COC raports thal Ihe ClKago EOCiu^ and running dua B a posstilB atlack in Chicago. 


Dala coilectoi Log 

Kane County EOC 

lA 

12-May03 

17 36 

{ 

VNN report RettCroes activates Wood donor system 


Data CWleclor Log 

HHS 

IL 

l2TUBy*03 

17:46 

Kane Co. receivqB EMNet EMigerKy lAessage that Lake Co EOC has been perfiahy acOvated because of 
Seattle bombing. 


Dala collector Log 

Kane County EOC 

m. 

I2-Mar» 

17:46 

V 

WA (governor's rffniin<iHnn of a Slate ot Emergency foiw^dad to siOC 


Washington National Guard Log 

WA State EOC 

IL 

12«May03 

t»«3 

lEMA notified CCSEMA that the IL SEOC made a decision to shut down as of I7ffi>. lacking any definitive 
information or credible threat 


Message 6 Event Log 

CCSEMA 


T2 /WR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reconsin>cii<>n 


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.. Date Tima _ ^ . 

Venue Descrtptlon 


Analyst Comment 


WA 12 May-03 18:08 Seattle EOC requests OHS pce-posAoned equipment package (PEP) located at Boemg Field 

Report to SlOC mat Federal Hazmat teams, mdudrfig firel Federal radtalnn detection team, have amwd on- 

lA 12.Hii,.03 t8:t0 


Data Coliacior 109 '''^1 FBISIOC 


WA 

12May-03 

18:11 

Hospital control iransierred lo Overtake Hospai Medical Center from Harborview MeAal Center due to 
broken water main at Haiborview 

rime cfiosan is whef> OrerUke confirmed transfer of ' 

hospital control 



IL 

12May-03 

18:15 

VNN repons mat IL Governor has ordered inereased security at nudear power planis 

, ^ 

WA 

12'May-03 

18:1$ 

PRUAC autPorizeO to d«[<ay. oslimaMd Ime ol amval in Sealtla at 181)0. 

f 

4 . 

WA 

12May03 

18:18 

FB I Seaiiie ERT amving at mcideni she 

A V' 


WA 1 2-Mey-03 1 8:1 8 FBI Calffornia/San Pranosco HMAT amviriQ or> sHe 








lA 

12-May'a3 

1820 

VNN repon Seattle hospitals receiving an ovenehekning nunSw o( pebents. 




IL 12May03 


WA 12 May 03 


Pro<Het alerts DuPage County Haalth Department to an nerease in attnseione ot patients witfi reepitory 
compisims to Edward Hoepaalc 




lA i2.May03 


IL 12MBy03 


IL 12MBV03 


WA 12 May 03 


16:40 FBI HMRU arnvmg on sKe 


18.4$ see raoetves Saattia casualty update: 2 lataMies and 82 noapdaksed. 


Chicapo DPH dacidat lo sand out dirty pomp information lo na puMe. Put ml waiilo sand out 
or the atari status 



ki 


FRMACLog KHUAU 

Data Coliaelor Log RDDshe 


Data Collactor Log RDOshe 


Data Collaclor Log HH8 


Dal.,Mlnc«nt Report D-P»9^eunty 


Data CoJiaetor Log RDOsha 


Data Contactor Log hhs 


Data Collactor Log Chicago DPH 


Blast fax sant lo 34 hoepaais on mformation about radtotogioal 
increasa surveiManca: took 48 rntnutas lo transmit 


1 8:S5 Hospital control translsr rad back to Haitorview Medical Cantar 



Data Collsetor Log Chicago SOC 


kicidaiii Log Hartorviaw EOC 


lA 12-May03 


HHS see set up lha CDC Emargency Comma System, and modHiad its SMHa id hignhoni radiMion 
mlortneiion, ? 



\ 

WA 1 2*May-03 

19.20 WA Governor signed the raguesl for 


Data Coliaelor log HHS 


Ooaraoons Section AcUvity Log WA Slate &OC 


lA 12-MBy03 


In the FBI SOC. presarsaiion of DNS's 
1923 Angeles, San Franctsco. Houston, and 

cftres wore cfosa to nudear power sites, H 


lA 

1 2May-03 

19:35 

DHS Secretary declared HSAS RED n SeaJ 





TSA Daily Watch Log 


Data Collector Log 


OHS/CAT 


REOC 


Data Collector Log 


Chicago SOC 



T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reconstruction 







FO R OFFIC I AL U SE ONLY 

DRAFT 


7/17/2007 922 AM 


Venue 

Dale 

lEDTl 

Time 

rFDT^ 

Description 

Analyst Comment 

Type al Beta 

Source 

Omanizettrm 

WA 


19:50 

SPD feouesitng FBI assisiaoce at scene ct ezploson. 

Briefing occurred at 17:30 FDT (20:30 EOT). Action took 
place sometime between 16:50 and 17G0PDT (island 
20:30 EOT), when the bnetvig took pUca. 

imeliigence Summary Report (ISR) 
Seattle Division ^ 

WA Slate EOC 

lA 

12Mdy-03 

20:00 

HHS see orOera two SNS sites nearest Chicage to be reaoleO for losdetg onto the airplanes. 


Data Cottocior Log 

HHS 

UVA 

12-May03 

2020 

OHS Secretary, >n consuiralon wtffi Seattle Mayor, has dedarect HSAS Red tor ihe Seatita/King County area 

ABo 'scoidM by a data coleclar at the FEMA lOF 

FEMA adivily Log 

WA Stata EOC 

IL 

12Mey-03 

2021 

Director of Chicago OEMC reports that a telephone cal irom Chicago Depi. ot Health A Hman Sendees has 
raised the alert status Irom Orange to Red. While awaiting conllrmaeon by Fax; aH CIveago OCMC 
nerannnel/anertnM wtl imnlement Red Alen. 

This actually reflects change in Chicago Health and 
hAjmafi Services alert status 

Data CoHecTor log 

Chicago EOC 

lA 

i2-Mdy-03 

2027 

DHS*CAT reports that OHS has acMseO that eftoctive at 2130 EOT, the alert level wM be raised to RED tor 
the fdiowing cities: SealOe, San Frano«co, Los Angeles. Houston, Chicago. New York, Washington, D.C. 


Sli.iatton Hagort 

DHS'CAT 

IL 

i2May'^3 

30:32 

Chicago area EOCs notHied o1 elevabon o1 HSAS to RED hy seven higivnsk cAes 


Oetalled Incident Report 

OuPage County 
EOC 

WA 

12May03 

20:40 

FBiarvtouneed that inetoen is a terronsi event 


Component Log 

RDD Site 

lA 

i2-May-03 

20:40 

HHS see gaB areid ol Ihe savaivcily Red: wil nooly COe lo load the planea 


Data CuHacior leg 

HHS 

WA 

12May'C3 

20:50 

SFO requested the release of DhS pre-'posrl>or>ed equomeni pecKige (REF) located ai Boeog Held. 

Request passed lo FEMA 


Operations Log 

WA State EOC 

11, 

IZ-May-OS 

20:50 

Chicago Fire Depi intormed by FBI Ctscago that Chicago is istod as a ‘probabla* target, increase seeurfy 
for ser>K>f elected odtcials - Governor and Mayor, Specilic ihreais have been idaniified 


Data Cottaclor Log 

Chicago EOC 

IL 

12May-03 

20:57 

CPU recommend oeneeieeon of Mvie Sox besehe* game and McComedt Place convention .Emergency 
Management Coordinator concurs. 1 2 hour shifts tor sworn personnal: aim urstorms. Contort specni 
ffMnrix at n Hern nnri MrSwav kw Cnrtn Red ofotorols inmnMtrf wi»r7-a try rJw tainel NiASnm 


Data Codeetor Log 

Chicago EOC 

w» 

12-May«3 

21:00 

WA Hoapilal Cowd caaaaa opaiiMna 


Incidenl Log 

HarOorview HosplUl 

lA 

12May03 

21:00 

CDC oparaiions cantef racerves message Irom HHS SCC lhal 7 odes are now al threat level red. EOC sun 
noMies asexiatad CDC suit mentoers 


Dau CoHoaor Log 

CDC EOC AlUnta 

lA 

12-Mar43 

21:02 

HHS. comemng w4fh Chicago haam otiiciais. warHs to pra deploy 9 * SEHT now; il wJ be thcro try immnQ. 

In another matter. HHS wil work with wNh RHA lo pre*poeition tUGjtoeiipiU near Chicago, based on 
^ffmirwivyi fnw Rmish Cnameva 


Data CoHsclor Log 

HHS 

WA 

12May03 

21:10 

SPD 1C meet with Mayor and Chwls at poAca command post: SP01C 4dvtsaa mat this was a larronai ever'i 


Data CoUaetor Log 

RDD Sfia 

lA 

12-MKy03 

21:10 

FBI SlOC levn mat 7 oMe nK go lo Had al 3t30. 


Data CoHaclorLog 

FBI SlOC 

lA 

12'May03 

21:30 

USSS Diracior's CriaK Canter activated 


Federal Responsa Briafing (Info Cut- 
OflTlme: 0600 13 May 03) 

DHS-CAT 

lA 

12-May-03 

21:41 

CDC ewTtir^ Out healh alert to Ch^rwaa doctws wto rH»|Mais. Piagua too be added to was^i w. 
based on irHeWgence. But CDC Is ndtiuggmw ouibmtfi of lh« dsease; Ihe aN 1 says to look tor flu. or 
bmUv rKnratnrv (Urmit 


Data CotlsclorLog 

HHS 

WA 

13-May-03 

21:44 

Saanls 5htiiei-i>H>laca pBSt raiaaaa aenoved 


Press Release 

Seatlla EOC 

lA 

12-May-03 

21:45 

HHS SCC received noOlcallon from 0E8 hbMDMS teams werMctivaiad (noUortolly) m response to HSAS 
elevalion lo RED tor the seven ctoea. 


Dau Colleeior Log 

HHS 

WA 

12-May-03 

22rW 

US Coast Guard Seattle is at MARSEC 3 (tvgnBSt level of security) • Dss means certain parts ot the Fort of 
Beento are closed anq pen trallie is beiog dr-eciM todthe* tocaiiona 


Situation Rapon3 

WA Stats EOC 

WA 

12May-03 

22.00 

DEST arrives at the FBI Seattle Field Office (cdfresponds to MSEL 9 3052). 

rme taken from JOC analysl tog (3tfier wnes mponed 

21 130 tfid 1 7t»5 POT (OIM and 20:05 EDTj by MSEL 

Teem Imm smiims 

Analyst Log 

JOCCMG 

lA 

12-May 03 

28.07 ' 

From ERA HQ 9E deeignaied as lead tor radtcriogical matters: other Federal agencies are to lake DOE'S 
direction on moi^^nng requelto C^OE is to recewe al data now, through 9ie FRMAC. but data can be 

^narwl iwvii BnrT kvi*! 


Dau C^leclor Log 

ERA EOC HO D C 

lA 

t2-Mav03 

22:30 

FEMA EST and DSHA looeerdlnale an inter-agency healdi & safety plan 


Data Collector Log 

ERA EOC HO D C. 

lA 

i2May'03 

22 30 

First SN$ snuanoft topoft was eaued by COC. Pnmary area ol cxxxdnation is sifiply of Prussian Blue. Ca 
DTPAorZn DTRA 


Daia Colleeior Log 

CDC EOC Aflanta 

WA 

12-May-03 

22:40 

National Controller called WA SEOC Director to ri|ecl that the national threM level went Red, effective 1740 

PDT 


Data Collector Log 

WA State EOC 


T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reccn«iA>eti&n 


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Venue 

Date 

lEDTl 

Time 

IFDTI 

Description 

Analyst Comment 

Ty|ie el Data 

Source 

Omanlaatinn 

lA 

12-May'03 

22:46 

NRC alerts FBI ireormaDon control that it is ocing to highest level security at nudear powrer plants. 


Data CcJMctar Ug 

FBI SIOC 

WA 

12-Mdy«03 

22:58 

FBI has completed trail vehicle evidsnce mves&gation. FBI identihed CLOOO involvement (conesponds to 
MSEL»3051) 

Tfme taken was from MSEL Team log (source RDD Site 
Ctodrdter). Additional bine 21:30 POT (0:30 EOT) tiom 

ROD Sle Data CoHedor. toentifying more actions than 
compleBon of vehicle evidence coiechon 

MSEL Team Log 

MSEL 

IL 

12May-03 

23:00 

IDPH put out fax aied regarding signs and symptoms (definitions of) d respiratory iness. fever, pam in the 
chest: 60 suspected cases 


Fa. Aftrt 

IDPH 

IL 

12May-03 

23:00 

DuPage County Putihe Heallh gets iWrtM^tnon trom IDPH of a TOPS cAister vtd passes itus notifieawn on 
to 6fl offices and hospitals 


AaSMIeies 

ILVCC 

WA 

12-May03 

28:00 

King County EOC tailed to JOC: confirmed event designaled as a teironst incideni and FBI assuming 
mvestigaiive lead. 


Componeni Log 

King Couniy EOC 

IL 

12'May'03 

2300 

Last night at 2200 • OuPage County notified from OPH - nolAed of TOPS* ciusler - Id al PH offices and 
hospitals 


Data Coliaclw log 

DuPage County PH 

WA 

12-MBy03 

23:10 

Oonfarence call with key stele, county, vid city players to update stalls of cunem sAiaSon: PHSKC EOC 
recommending: safe to rerrxtve shelter in place, but unsure how to irartsport those people out of Exckisicn 
Zone. Win bnng n buses from outside the Exclusion Zone lo evacuate the public— leH them to go home, bsg 
doihss, put m garbage, shower with water and soap, and awas lurihar insihiaions and Mo. Fmal 
FlecommendaMn: risk ol confewlng to shelter in place is greater than contominalion thraal of laaving tha 
area. But, want to inmsport people out of area usmg non contaminaied vehkses brought to perimeier of 
modent area 


Data Cotieaor Log 

SKCPH EOC 

lA 

12-Mey03 

23:23 

USMS rspons Federal courthouse in SeaiOe Is closed, but a magistraie remains on duty. 


Daia Coltoeior Log 

FBI SIOC 

WA 

12-May03 

23.30 

Ineldsnt has been declarsd a crtminal act: FBI has assumsd conbol of the meideni site 


Daia Collacio' log 

RDO Site 

lA 

12-May'03 

23:30 

Washington Stale reguesi for FedersI Disasier Oedaraiion aubminad lo Whae House 


federal Response Briefing 

DMS-CAT 

WA 

12'May«3 

23:34 

Incident Site Update: Command staif transition taking place: HazMal and lechirscal rescdioperaiiorts sil ofr 
going, new tents and kghis being ereeisd in command post Aea for nighi operaiions .sre and SFD 
cammarxl posts stds by lids but separate. Sol r>o unitred comrrtand. Federal agpieise on scene :nck)do 

FBI and ERA in command poei area. 


Oaia Collaelorlog 

ROD site 

WA 

12'MlV'03 

23:50 

FBI has dsclared eveni a lerronst ncKlant effeove 20:00 POT (23:00 EOT) k assumed lead fnm^#ve 
agency roia investtganon has associated a Maroon Honda & a blue GUC pid^ io imck woh ihewdn 
Hor>08 recovered near seen# after crash with one non siemlfiad suspect dsad-on'srrtval. BKr# pcfc-up 
believed headed north.bound towards Canada. 


King Couniy OEM Event Log 

KC EOC 

WA 

12May'03 

23:56 

Data Irom AMS recetvsd by FRMAC. 


Oala Collector Log 

FRMAC 

WA 

13May03 

0:00 

King County Situation Rapon • King Courtly Metro Transit has trvade vartgemcnis lo provids Waier Tan * 
service from West Seutte lo downtown Seattle al 8*15 POT (8:15 EOT) Tuesday 


Press Reiesse 

KC IC 

IL 

13-May-03 

0:U 

C«nirsl Oupngt Howial alMW HmiVi Oepi ol a eu«p«cwd plague can 

Tha evaluabon leam does not know s Heallh Dapt. rafars 
to ihe DuPage County Health Dept, or to IDPH (or bod>| 

OalUM Incident Report 

DuPage County 
EOC 

WA 

13-Mey-03 

0:18 

All patients have been rescued. ts clew of live vieims 


Data Collectcir log 

WA Slate EOC 

WA 

13 May-03 

0:16 

Ongoing discussions between WA SfidC. Kng County EOC, and SesTHe EOC% and public heallh oHiciafes 
about shrinking the excluaon 2ona. Than n n rtrnpajjxImflriMmg itfmiit itR^h nf (Tars 


Oala CollaclorLog 

KC EOC 

WA 

13-Mar'03 

02S 

Conference CaN between WA S60C (indf^ng WA QDH). King County EOC. Seattle EOC. and PHSKC 

EOC to develop evscuabon plan for people sheliedng in place r mdusinal area of exdusion aona, Firsl 
wash down evacuation rouia<s). eoordhatarbuvs mio Ihe modei^rea. SFD. SPO. ar>d DOT available to 
support the evacuation. Evacuated people be taken to a holdmg area, where letabves can coma gel 
them or they can go to shelters. Al hoUmg sse. 4reclior« wiH be grven lo people about tiow to 
decomvninaie at home (remove dotfung. bag'tttem. shower with soap and waterj. There is an unknown 

be eveciieM# wiH wart on more lab data before avuatmg those East of 1-5. 


OaiaColleclor Log 

SKCPH EOC 

WA 

13-Mar'03 

030 

Vbi has ovorahtbommand and SFO has rescue command. FBI wil be on scene al ni^ 


Data CoHactor Log 

RDD site 

WA 

13-Mav 03 

0*30 

Unified meetingatiade up of SFD. SPD. and FBI. to cksciiss overal sAiaSon ai rodert site 


DataCdisctor log 

WA State EOC 

WA 

194riay-03 

lOO 

FBI HMRU Leadirs decisiori to have fmH emry learns was based on number ladors: Desire to fadhtate 
interagency cooperation, todCtotta^ concerns with |uri8<ftction—the moesd teams would alow tor a 
representative Iram agoinplhal daim to have pmsdictiQn of the evidence: levels ol experience - some 
agenctes have rnere euftonce wtih Has) anatysto. 


Dale Collector Log 

RDD SFts 

WA 

13 May-03 

1.05 

WA SEOC Lisl ol Prtortty Actions: 1) RaAatfon footpnni and impacts. 2) EST Recovery and Restoration 

Task Force. 3) QBcat Intrastruclure Protection. 4) Re-openng of 1*5 5} Presidential Oedarabon 


Dala Colleclor Log 

WA Slate EOC 

WA 

13-May-03 

1£9 

WA SEOC repofts: SFD f-lazMat contrms deteebon of Amerkaum 241 and CesHan 137 and relays to IC/ CPS 


Data Collector log 

WA State EOC 


T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reccnsirveti&n 


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Venue 

Date 

rSDT) 

Time 

lEDT^ 

Description 

Analyst Comment 

Ty|iM80eta 

Source 

Oraanbetirm 

WA 

13-May03 

UO 

Global e*maii 10 King County Employees: Only essential King County personnel who's iob site is within the 
foltowinQ boundaneS"Roydl Brougham lo the North. 1-5 to Ihe East, S. Alaskan Way to the Soutfi. and EKotl 
Bay 10 the Wesi-are being tolO to report to work tomorrow, Tuesday. May 13. Employees are advised to 
check wtrh the King county employee hollH>e. al 205-8600. and the Kmg County Websiie, at 

WWW metrokc.gov tor department specific iiSormatton 


Press Release 

KC IC 

WA 

13Mdy-03 

1:37 

WA PFO priohties for night: defining the affected area, developing protective actions, and ccn^iucl^ a 
conslsteni message to the communities. 


JOC CMG Log 

JOC CMG 

WA 

13-May03 

1;4S 

SFD determined no viable victms left at incideni site: swilehing from rescue mode to recovery mods. 


Fa Log 

WA Slate EOC 

WA 

iaMay-03 

2:00 

Data from DOE AMS idsnofied an alpha eminer. FRMAC iherefore bsbeves Ital ths staler in place 2ons is 
too smaH. Seatlle's initial assessmem was based on rfAiit from only a gamma enstter (Ce 137) at relalively 
low levels. FRMAC recommends 10 WA PFO that Seattle evacuates 3 H people in evctusion jorts, but need 
ground samples K> determine exact measures. SPA'S makes recommendalkm to wait until mommg (SHice 
people are sieepmg) when rnore data has come ei»Staie and locals made the best decision they could wkh 

The mformalion ihey had at the Ume. WA PRO'S dectson is lo recommend (o the dly to mantain shelier in 
place urtlii more data comes m; not to evacuate. 


Analyst log 

FRMAC brleflt^g 

WA 

i3May03 

2:02 

WA PFO learns that Seattle is planning lo evacuate those civiians who have been sheltenng in place ei 
indueirial area 


Analyst log 

FRMAC briefing 




WA SEOC faxes a reguest lor The DMAT to the FEMA Region X ROC. They went a metkcal learn to do 



FEMA Reo«riX 
ROC 

WA 

13-Mey03 

2:10 

enhanced primary medioai care 10 augment overwhelmed local emergertcy departments due to potential 
alfected populatiort zone & '^womsd wer and screening tor emergency reserve. 


Fax 

WA 

la-MeyOa 

2:12 

WA DOT; City of Sesnie recommended opervng of stale htghways, but ihey lack ttw aulhonty 10 do so. 

This occurred between 23il2 23:40 POr(2 12 2:40 EOT) 

Data CoHeetor Log 

WA State EOC 

WA 

13-MBy03 

2:50 

Discussions ensue al the Seatfle EOC about plans 10 deconumnaie iha sheets by washmQ thwidown; 
concerns ere raised about Ihe sewage systetrv pcieneai legal ftsuas. end envronmentai mggpt 

Thia occurred between 23-50d>0:« POT (2:50-3:15 EOT) 

Daia Consclor Log 

Seattle EOC 

WA 

la-MeyOa 

3:12 

KC EOC reports thai Seethe has put out a press release asking people lo slay out of cBpminated araa. but 
peopia can go ID work downtown, ^ 


OataCoUeaor Log 

KC EOC 

11. 

13-May.03 

3:5S 

leGrang* Hinpiui tvaKiaiM airram MtitiKt and aSanatad a poasiMa eaa* ol praumonicMSB* 


DM Coiiecior Log 

LaOrange Hospital 

WA 

13-May'03 

4:00 

Decision le mede for the SFD u remain m charge of irndent scene anal 8:00 POT (9.00 EDT) TuvOif ikhen 
fuB FBI returns 

This occurred between 01 «) and 0t;30 PDT {04.80- 
04:30 EDT). 

Dell Colleclor Log 

RDO tilt 

WA 

13Mfiy'03 

4:35 

Plena to go forward with the evacualion of Ptose sheltenng m piaca In Musirai area ol exclusion zone •$ 
hampered by e lack of date. 


Daia Colleetor Log 

WA State EOC 

WA 

i3'Mar.03 

500 

WA SEOC racommands lo USCQ 5 Harbor Pabol u reopan sw naidgibia wata'S > 0 , iba (allowing 

Wasblngun Stale Farriaa: vahicia and paasangar sarvica only on ihe Snacortas-StfiJuan. Edmondt* 

Kingaion. and Faunpamy.Vaahon.Souibwonh. Paasangara.only aanrica 0" me MntoncoCiinian, Kaysiona. 

Pod Townsend, and Pon Daltanca-Tahlaquah rouiaa. Recommend aaaonry niaaauraa in placeJDr wetK on 
paaaangara u lamain in aifect. 


Prcrfactive Acinn Dec4ion Wkaht 

WA Staia EOC 

WA 

13-Mey-03 

5:00 

WA SEOC laconanands inal ea oaavlWway doauret wnam FI aflacl ' 


ProlKtIve AcMn Deetilon Wkaht 

WA Slale EOC 

WA 

13-May03 

5:42 

WA SEOC Press release: WA OOH to begin evacuaaon of invni>d<att Uact a«a. People w« be nottfied by 
radio and by direct phone caHs mo the^a west of 1*5 uRog telsphone rWbers listed on business licenees 
ir> the ctty finance department The area to be evocuafiKl i$ botmded by Royal Bioughavn Way on tha north, 
hS on Ihe east. S. Alaska St, on the soutrvftnd tbg Soartfe waterfroM on Ihe wesl. 


Press Ralease 

Saattia EOC 

WA 

i3'Mar'03 

6JB 

WA SEOC notHred (hat Seattte Mayor deodc^-S wil re*open ai OSXXI POT (08D0 EDT) 


Data CoUedor Log 

WA Slate EOC 

WA 

13-Mav'03 

625 ^ 

Pen WOOT. radiological data haa nol been confamid Tbeiafcira 1-5 wM lamam ckisad. 


EOC Supervisor Log 

WA Slate EOC 

WA 

13-Mar'03 

621 

h 

SeatOe EOC: RVacled opening ol 1*5 unol addihonei data from DOE AMS fly over comes ei. 


Agency Log 

Seattle EOC 

lA 

13ltjl7'03 

7:10 

HHS ASPHEP requests CDGtt^conlact SERT leader tn Chicago and tel hse to request increased 
survetliar^ COE agrees lo cel Chicago. 


Data CoHedor Log 

FBI SIOC 

WA 

7:15 

SFD IC 8 OperatronsChtef rrwet lace to face wHh NMRT. NMRT tasked weh force protection 


Data Collador Log 

WA State EOC 

WA 

13-May-03 

7 - 3 ? 

WA SEOC rsqueals Fire Mobilization AuPianzation on benall o) SFD 


PuOltc intormaton Officer's Log 

WA Slate EOC 

WA 

13-May03 

7 : 45 ' 

WA SEOC Haws Release: WA Stale Ferries lo resume tuH service aircepi lor Seallla runs. 


PuWc intormaton Ohicehs Log 

WA State EOC 


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Venue 

Date 

IfiDTl 

Time 

IFOn 

Description 

Artalyst Comment 

TypoHOfiata 

Source 

Omanlzetinn 

lA 


9:0$ 

NCEH. lead CDC came' reeponcSng to ladological evem, conducts coniefence cal wtfi Setffle & King 

County £00$. Regional X REOC. and COCs A-leam represemattves. 


Data Coll ecior Log 

HHS • see 

(L 

1 S'MayOS 

8:10 

ARC o' C'eater Ctucago recerved a phone cal from IL SEOC: confirmed Red Alen tor IL becanw effective at 
1920 CDT (20:00 EDT) on fi4ooday. Also informed that IDPH has reported about 100 palienis «rith SARS-Ihe 
symptoms have reported to Chicago hospitals. Due to tWs, ARC wH discontinue btood coHections in iMs 
area. All chapters will be noofied of alert status. National ARC ^Qel into Pubic* Mo bne has been activaied 


Data Coileclor Log 

ARC of Greater 
Chicago HQ 

WA 

19*May-03 

8:30 

WA SEOC News Release: WA Governor appointed a Recovery and ReeioraAon Task Fwce to gutoe vto 
coordinate stale government recovery eftons in areas o1 King County and Seattle affected by the explosion 


Pnoerfiatoase 

WA State EOC 

lA 

13-Mav'03 

828 

9EMA HQ calls loi a COEia mealing ai 0900 on May 13. 2003 


Data CollectocLog 

EPA EOC HO D.C. 

IL 

13Mey-03 

M 

DuPage County Public Health Dept, goes on 24/7 ops 


Data CoiiecTor Log 

DuPage County PH 

(L 

i3-Mav-03 

eA8 

Highland hospital recerved darriication Irom lOPH mat * wasn1 the alert level that weiS to reck >t was the 
mfeetton alen level 


Anafysi Notes 

IL VCO 

]|. 

13May03 

6:58 

DuPaga County Public Health lo gei surveMance ie«ns up and going 


Oeia Collector Leg 

DuPaga County 
Health 

WA 

13'M>y'03 

9:00 

WASEOCwasnotifiedby FEMA Region XLuuson that the POO was signed al 900 £$T on May 13 WA 
SEOC « trying to obiam a copy of signed dedaraffon at iNs lime. Dtoaster number wfl be OR'432i-WA. 


Sffuelion Report 

WA Siata EOC 

lA 

13-May-03 

9:12 

HHS see holds a contorenee cell wih Region V to decuss btotogtoal event Key discussion points: NCID is 
the lead CDC center supporting ihe bto event; needs lo engage Slat# A local health offioals to convey 
prophylaxis strategies. Commumcalions stall coordmate with locals to develop messages tor me^ and 
pubiK 


EPAR Sdirvity log 

DHS/ HSCama, 

IL 

13-Ml)r'03 

9;tS 

CCOPH begins active surveiilar>ce. Contact Chcago hospilato by lax. bul don't dtscuaeiKase with pub!«c 
yet. 


Dale Colleeior Log 

CCDPH 

WA 

13-May03 

9;1S 

FBI locales two safehousee (correeponds lo WSEL ff 3053) 

Tiin* takwi wa fro'h a RDO SAa convoiw leg. Otha, 
umaa HIM Or MSEL Taam wan 21 HO and 22:30 POT on 
Mar l2(0:A0and 1 30 EOT on Hay 13J iHm unknown 
aomcaa. 

Controller Log 

RDD Slis 

WA 

13May03 

9:13 

Seaiile Mayor signed a general exeluMn order, winch resirictod pubic eccees in an area bourxM by S 

Honoh $t. on The South. $R99 on tot West, Royal Brou^iwn on tot North, and Aepon Way on toe East 


Seaffle EOC Situation Repon 

Ssatile EDC 

IL 

13-Mav03 

9:23 

S ^ r* 

DuPage Coumy OPH aiens pre selected prophylaxis dttpensmg sites Iftpe picpiitg to be odnosKIn iha 
«WK Dial Ihe IL SlocKpila or SNS e regueeieO. 


Daia CollaolofLog 

DuPaga County PH 

IL 

13-May03 

9:30 

Chicaoo Dept, of Pubke HeeHh dt$petoheeepidem:oiogy teams to 34 Chtca^zclty hospnals 


Dau CoHador Log 

Chicago EOC 

IL 

13*May-03 

9:30 

Lake Forest hosprtal recerved fax corl^nrupg pneurggnic plague. Fax alsb recerved legaroing pabem flow. 


Data Collector Log 

Laka Forest Hospital 

lA 

i3-MBy-03 

9:30 

DOS Stood up task force to haison with Canadik Border securtty he^jhtened . Canadans are mteftepeng 
SeaMe4iighis lor possible decorHaminalton 


Data CoHaoionLog 

CDC EOC AUanta 

IL 

13*l4ay03 

9:37 

Cn>;sgo EO^ftM received only ffree reports Mkn 3 ho^Jilals: Ctacago OPH to send staff out to hosp4al8 to 
do face-To-fac^ emphasoe increased reporting Chicago DPH advising M-95 masks and infection control 
procedures tot Btoerpency responders. 


Data Colleetor Log 

Chicago EOC 

IL 

1»Alay03 

929 

Chicago EOC pr^poeitionedepeoakzed tevns (hazmat, dive, rescue): tocAed down firehouses; acUvaied 
secondary comrrtond cost at Fire Academy 


Data Collector Log 

Chicago EOC 

IL 

13-Mav 03 

929 

IDPH acTivatas PFase 1 of IL Emergency Medx»l Disaster Plan. POD ho^als activated. 


Data Collector Log 

DuPage County 
Health 


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T2 Reccnsirveti&n 


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.. Date Tima _ ^ . 

Venue Descrtptlon 


Analyst Cofnioent 


IL 1 3 Mdy-03 9A0 Loyola Univaf»y Madtcal Canter aciivaied as a POO Hospital 


IL 13May-03 9:43 


Chtcago EOC nolriM Mayo<'s CMef of SlaH and brought Mayor up to date; m coftael with IL Govomor’s 
Office: iTtore senior staff reporltng to EOC: preparing Chicago Oedarabon of Emergency draft. 


(L 13-May03 9:4& 


Highland Park hospital received cal from lOHNO to go to Phase I of IL Emergency Medkal EKsasier Pian • 
must repon bacir to iOHNO 10:30 CDT (1 1 :30 EDT) that ptan is mvlemenied. 


IL 13 -May 03 


IL SEOC Director spoke wih ISP Director and reported to IL SEOC: Eased or^ mteHigance Mwtwon last 
night the North and Ceniral (with the Southern team in reserve) SWMDT, Naoonai Guard $th CivH Suppon 
9;5l Team, and IMERT are being acovaied. ISP w*H contact Iher membars and lEMA to make remainder ot 

contacts. They are to report to the College Of DuPage IL S60C Drecw also authoraed the a ovaoon of 
these special teams. 


IL 13 -May 03 


IL 13 -May 03 


IL 13May-03 


WA 13MBy03 


IL SEOC rKitifies ARC Chicsgo Dkstnci Operations Center of 2 cases of pneumorac pfague, m atHMir 
9:5S SARS • like patterns presenting et hospitals over night. Also notifies that IL SWMDT has beehW'up in 
Dupage County 


Good Semarlten called Etmerst Memonaf Hoepilai ER to tel charge nuree that Phasa I of IL Emergency 
Medical Disaaier Plan was implemented. 


IDPH eonlerenee call with lOPH Lab; Top Pnohly lor hospriaf labs is H Ihey see bipolar stam'ngiHfng Oram 
10:00 stain and patienis lit ehncal picture: sputum sarnples. Bronchoalveoltf Lavage, lung aspirat^n. Aoltaloiic 
suuephbirily. 


10:00 Threat update: Stale of Washlr>g(on, orenge. Citv of Seattle. red?Mlng Coimty, red<based on local pofecy 


lA i3May03 


.... Canadians requested mat they be^ta|M to send a hason to Region X RCA US Qovemmem has no 
oOiections. ^ 


IL l3Msy*03 


Lake County DPH reports: Hospitals 
as suspect SARS, Some cases were 
’ COT on May 1 2 (0:42 EOT on 1 3 May), 
tllness United Center Connection, 0‘Ha 



went to Unf^er Center are bemg reported 
Hospital suspects plegue at 23:42 
OuPage: 1 3 suspect cases respiralory 


11. 13-May-03 


lUtnois Masonic activates Phase I of IL Eiit wA iicy Medical Disaster tan. Metois Masonic taxed Swsitah 
Covenant Phase l intormaiion sheet becaugerftey (M not have H. though they are sr^posed to. 



mergency Medicaf Disaster Plan • charge nurse 
. vents • etc. 




ospital activates Phase I ot Emergency Mecfecal Disaster Plan 
number of flu-bke ikriessee In Vancouver 
of ARAC plols 


Rad Cross of Greater Chicago PIO recerves request from PEIM to go lo the L JIC 


T2 AAR Annex A - T2 MASTER RECONSTftuCTION 
T2 Reconstruction 




Ty|ie el Pan 

Data Collector Log 


Loyola Univ. Medical 
Center 


Data Cokector Log Chicago GOC 


DaMteiM^Log 


Highland Park 
hlospilaJ 



SEOC Event Log 


Data CoileaorLog 


Data CoileaorLog 


CCDPH Log 


EOC Supen/eor Log 


ARC • Chicago HQ I 


Elmhurst Memorial 
Hospiiai 


Cook County DPH 


WA State EOC 



Situation Repon 


Data Collector Log 


Lake County Depl. 
of Health 


Data Colleoior Log 


Swedish Covenant I 


Date Collector Log 


LaGrange Hospital I 


Data Ccdlador Log 
Data Colleclor Log 
Date Collector Log 


Central DuPage 
IDPH 
FBI SIOC 



Data Collector Log ARC • Chicago HQ I 











FO R OFFIC I AL U SE ONLY 

DRAFT 


7/17/2007 922 AM 


Venue 

Date 

Time 

IFDT^ 

Description 

Analyst Comment 

Type el Pato 

Source 

OmanizatiiMi 

IL 

13Mdy-03 

10:30 

IDPH {^mgfield): al specimens need ro be expedited lo IDPH Lab for delMdve CUgnostic lesOi^ 


Dald Collector Log 

IDPH 

lA 

13 May-03 

10:30 

Homeland Security Center update: CDC recommends starting with CproAoxadn wid then switching to 
Doxycyerme later if a^/tsaOie to do so: Several people have arrived in BC vAh have iMfce Mness. on a 
oiiginabng Imm Chicago: HHS wohung to get SNS moved on a minute's nobce 


DOE activny log 

DHS/HS Center 

IL 

13 May-03 

10:32 

DuPage County DPH suggests (Pspateh IL State Pofece or local police as couriers to expedbe tab analysis 


Data Collector Log 

DuPage County PH 

(L 

13-M8y'03 

10:36 

Lake County Health EOC advises Lake County EOC: 89 cases m Chicago area - 1 death from resyatory 
liirtass Samples sent lo IDPH Lab • prelimnarv resUls by noon • possMe outbre^ of pla^ per CCOPH. 10 
may have been ai United Center. 


Bala CchactofLog 

Lake Couniy EOC 

WA 

1 3-May'03 

10:40 

Debriefing meeting with IC; TransAoned irom rescue to recovery at 061)0 POT (09D0 EOTl FBI takir^ over 
responsibililiQS for nodent managemeril. Scene monHortng (comemlnants) s6l being performed by ^0 
HazMat. Decontamination responsibaiiy transferred to NMRT. JurisdicAon over deceased disrvissed. OMORT 
on Site by 11:00. 


Data collector tog 

RDD Sits 

IL 

13-May-03 

10:41 

IDPH: Priontize specimens by bipolar saaming or ccrmecfion with United Center 


Oaia Collecior Log 

IDPH 

IL 

13-May-03 

10:47 

Fmaized TOPS' case definition deeciibing sigrts and symptoms of mfaclious disease trend beginning to 
appear. 


Bala Cohscior Log 

IDPH 

IL 

13-MBy-03 

10:54 

IDPH r>oiilied ARC Chicago they have activated Phase i of ihev Emergency Medical Disasier Plan • lOPH 
collecting data and checking ho^iai space 


Data Collacior Log 

ARC - Chicago HQ 

IL 

l3-May-a3 

10:SS 

ARC of Greater Chicago reports that ihe early ekrHcel diagnosis Irom ihe A SEOC <s Incprreci; there is noi 
enough information lo conirm Ptague 


Oala Collacior Log 

ARC - Chicago HO 

lA 

13 May'03 

10:57 

Saeile FDA ofNca preparing an advksory for consumers: btankei ambsrgo of al foodstuffs injpe pfums arsL 


Data Coileetor Log 

VA Central Oftica 

WA 

13-May-C3 

1059 

AMS tty over readings: KHsap County {WA} readmga are above food ccrnrol imit: 1-5 laalvan, but people 1 
could drive into unsafe areas • so not ready to open. Cvy rsouesis maung restrienui area east of !•$ a 
pnorty for measurement. 


Dau ColiaoiorLog 

WA Slata EOC 

lA 

13May03 

11:00 

HHS see holdi cor9»rence cal nilh eOC and oitier ESP.6 padners: key d:ccucsion poinis' NCBH iCVC 
rsdlaiion Md) nu posud woiMt ulpty tadiaMn Haiaiuta on COCI atacaiia {aoma iril(innai.on a ac&ially 
on tna ilta, wPla olhar inlomiaBon ts nobonalV poslad). HHS SERTa sent >o Saalila and Chicnpo. 

Raviawad currani rnttaion aaognmanianquaais loi asaiuanca lor dia ataiaa Saama na$ taquasiodjha 
lollowmsESF easaats: OMAT. NMRT. OMORT and ina WMO BMQRT. Addmonall>. OOC providad A Tam 
mampati lo tucpon FRMAC 


DBia Coileetor Log 

HHS see 








IL 

13-MIV-03 

11:05 

mocaiioni met BooniDnai cases were preserNiriQ whm sympv’i'eene^spesiBS^S cuMBeient wvi 
ptague, but no dear lnd«alion Ihal’s inhat * «. Cases showing tromttfare arKrtHUun^jBimt m addfnon n 
Urutad Center. 


Bala Collacior Log 

CCDPH 

tL 

13-MBy03 

11:09 

Chicago EOC update: FBI is at Ihs EOC; 2 no^rtals (GotOiab and lnga«|^ report cHwcei piegue jpfiss « 
hospital • the coses corns from tar south and far wesi ol Chcago. but bottfltended recent evm at Ihe 

Uniiad Center; the HAZMAT Chief and City ol Chcago nofitiad. 


Bala Collacior Log 

Chicago EOC 

IL 

13 May 03 

1l:10 

CCSEMA tacenaa lEMA SKRap: aifiB-tarfrf (10:1S EOT) IL Stale WMO Mm S IMERT ware acWMad and 
otdarad to aaaamble al CoMga ol Di^apa ^ 


Message A Event Log 

CCSEMA 

lA 

13 May-03 

11:13 

2nd SERT team la arriving aeon in nm^; wF ^odMiorial eptriemiologcai. support from COC. 


OBia Collecior Log 

OHS CAT 

1A 

13-May-03 

1120 

Director CDC public health priorities; Fogi^ on tmiDsMe needs ol CMcego and SeatDs - but do not over- 
commit COC resources, as we need lo cofVidor poterr^a: for iqidlipie events n odier parts of the country. 
Ensure the public heafih communriy stake htfogis have Ihe requispe viformaliori lo stay mlormad as to whal 

18 happanirtg. NCID staff needs (0 gtrategize On the potenCal efiagnoais of plague, and be ahead it in fact Ihe 
agent proves to be piapue. 


Data Colledor Log 

VA Centra Office 

iL 

13-Mav-03 

11:30 

VN^HnnObrees patients with tiu-lke symptoms - possible $AR$ oases * in Chicago; unconAnneci deaths 


Data Collecior Log 

ARC of Greater 
Chicago HO 

IL 

i3'Mav-C3 

11.32 

At lOPH Lab.auggssHan made to irtikze “pofico^ get specimens Irom hospitab to IDPH lab. 


Bala Collacior Log 

IDPH lab 

iL 

i3-May-03 

' 11.40 , 

Bnefing at Chtcugo 91 1 : conSrmed pneumonic plague at Gottlieb Hoviial in Mefrose Park. Ingals - Harvey 
and Childrens Kgspttal'Chicego FBI noiHiad Chicago Fire Depvenem that the commonality is the Chicago 
United Center, Q^rcogo FireTlepartmenl is sending teams to idenlitv it baefena sbl present 


SEOC Event Log 

IL State EOC 

WA 

13-May-03 

11:40 

Red Cross reprewntahve tgT9H dOC CMC: King County Pvks Dept. w«n support from ARC opened 3 
shelters at 20:0(^OT aoWay 12 (23riX) EDT) for mdividuab unable to letom to their homes. 


JOCCMGLog 

JOCCMG 

\A 

1 3 Wail liW 

11:40 

INJECT: F9I ChicagD Field Office notilied that COC deploying assets lo area (MSEL 3129) 


Data Collector Log 

CDC EOC Atlanta 

4^ 

13-May 173 

11 56 

TSA liaison to F^SiOC New TFR will be announced with 5 mileradtjs, 18,000 feet (reduced from 204100 tt) 


Data Collector Log 

FBI SIOC 

U, 

13-May03 

IMO 

VNN omtirms QLOOO has claimed responsMity tor SealUe anacA 


Bala Collecior Log 

ARC - Chicago HO 

IL 

13-May-03 

12.00 

Ciscago DPH looking to idenirfy travel history ol al patients. 


Data Collector Log 

Chicago DPH 


T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reccnsirveti&n 


DRAFT 

FO R OFRC I AL USE O N LY 


Pa9@ 14 of 29 
















FO R OFRC I AL U SE ONLY 

DRAFT 


7/17/2007 922AM 


Venu& 

Date 

rfiDT) 

Tima 

rFDT^ 

Description 

Analyst Comment 

TyiMWata 

Source 

Omanizatirm 

lA 

1dMav-03 

12:00 

ESF 10 repons missing sNpmem o1 nuclear maienal 

Also reponed to FBI SIOC 

Oaia Collector Log 

FEMA EST 

a. 

13-May03 

12^)4 

CCDPH Conference call wHh Chicago and Collar Ccvnies* Reports coming from hosplals. but do nol have 
active surveillance. ElS otficars «aI ba going oit n the field lolowng conference cal. Stale recommencb 
that iniervievvs should ask whether they have had eiposore lo O’Hare. Lkaon Slalon, or Unitod Censer 


CCDPH Player Log 

Cook County OPH 

IL 

13-May03 

12:04 

CCSEMA receives Sftrep from CCOFH: 1020 CDT (1 120 EDT), lOPH has made a presumptive diagnosis 
of 2 cases of pneumonic plague. DHS nolHied i SNS placed on standby. 


Message & Event Log 

CCSEMA 

IL 

13 Mey-03 

12:05 

VNH: IL Governor press release anoouncmg confvmaDon ol pneumonic plague cases and that stale disaster 
plan has been implemented 


Oaia;GBllaetor Log 

Sphngheld IDPH 

(L 

13 May-03 

12:07 

IL Governor announces respiratory lUnass caisters m Chicago area. No eviderKe that ilness 6 related to 
SeatOe attack, but IDPH and other public heaBh depanments are working to determine cause of Ilness - 
urges citizens to lake precautions 


Data Coliecior.Log 

ARC - Chicago HQ 

WA 

13-May-03 

12:09 

*There are no confirmed dead* • per Kmg County Metfcal Examiners otfica. who received information drectfy 
from ihe IC 


Data eolieetor log 

SKCPH EOC 

IL 

13-Ma»-D3 

12:12 

Chicago COC: Plague is strongly suspected. Locks hke plague under mcroscope: several cases Itnown: 
many cases commg m nghi new. lOPH has 109 cases. Chicago had $ cases, other counbee have more 
Chicago OEMC wants real numbers as soon as possible 


Oala Collgelor log 

Chicago EOC 

IL 

13'Mly'03 

12:13 

Director Chicago OEMC: Via FBI Chicago, resputf ory pabenis from OHare and Union Station at Unedo 
htosprtai Chreago Fire Dept, to do irrvespQaitve biO survey at O’Hara •r>d Union Staiioa Plague presumed 
until luithar notice. 


Data Coiiaclor Log 

Chicago £OC 

IL 

13-M6y-03 

12:14 

IL SEOC received EMNel message Infotmanon 6>8i lOPH has made a presumpbve diagnosis of 2 
pneumontc plague cases. The Dapanmenc of Homeland Security has nobbed; the national 

pharmaceuhcai sfociiprit iSMSi to be on standby 


SEOC Eveni Log 

11 State EOC 

IL 

l3-Mey-03 

12:15 

Chicago EOC recetvtd EMNei Emerganey Message. IDPH has made presumptive cfagricflFOf 2 pnoumonie 
plague casea. Chicago Dept, of Health 6 Human Services has riobhed SNS to be on sMlby lor release 


Data Co<laoior log 

Chicago EOC 

IL 

l3-May-03 

12:17 

Lak« CouiNy EOC: IDPH Has ms(M pratuinpliva (Ugnocis c> prwumonc plagua. < 


Daia Coilaaorlog 

Laha Couniy EOC 

IL 

13-Mey03 

12:16 

Lake Courtty EOC noeAed emergency sloclipiie (SNS) lo stand by 


Dali Coiiaclor log 

Laka County EOC 

IL 

13'Mb7-03 

12:20 

IL JfC oonftrma reports ol plague. 


Data ecliecter Log 

DuPaga Co. EOC 

IL 

IS-May-OS 

12*36 

CCOPH directed staff lo develop public mformaiion message and get a phone bank ready and notify the 
BriOgevtew Oistrlbubon sat. red cross, shentf. pubtc heehh clm<BipaRd the PIO at the IL JIC 


Data Coiiaclor log 

CCDHP 

IL 

13-May-03 

12:40 

Chicago 91 1 Brleling; City of Chicago putbng logathar Ddasier DvBsoBBBbk] on iheir activiiiea dealing 
with health symptoms 53 yr lemale af>d 57 year male Unied Fhghi eticr'dant both cor>f:rmed dead by CooK 
County medical examiners. Chicago in commuottafion wHh Vancouygs bcccuso Vancouver played CNcagb 
Black Hawks this peat weekend Clecago Fpre Dapartmeni. Chtcago Bomb Squad, and FBI are checMfig 
United Center, Union Slaton, and OHare Airpon. Considaring a requattfer CST ream. 


SEOC Event Log 

IL State EOC 

IL 

ISMay-OS 

12:45 

Chicago EOC updaie: State of Emergency to be declared in In Chicago. %trrimend pubbe Sheber*NhPiace. 
Streiegic Nahonal Stockpile requested. Final trigger was a massaga from Vancouver seymg that thair iniMi 
cases all came horn Chicago ar^d (hat^Bwi microb'oiog'sts'ieba had coi ih irt^Pneunonic Plague. 


Dale Coiiactor Log 

Chicago EOC 

IL 

13-MB7-03 

12:46 

Kane County EOC received an e^maiiftm lOHNO * WMDCmI S^1pon teaioe and MERT activated arid are 
to stage at coilega ol DuPage ** 


Data collector Log 

Kana County EOC 

IL 

IS-May-OS 

12:56 

Cook County EOC preparing procfamettorrel dtafffsr 


Data Coiiaclor Log 

Cook County EOC 

lA 

13-May-03 

12*59 

HHS reported 2 cases with prasumptrve plagEia diognofts and 100 addrhonaf sick wSh Au hka syirptoms in 
Chicago. CDC « at (he scene with an mvesu^Dve team. DHS « conducting conlerenee caHs to confer on 
pavnoh achvities 


Situation repon from Bureau cl 
hnmigiabon and Customs 
Eniorcemetii HfeadQuarters Reporting 
Center 

OH8«AT 

WA 

Id-May-OS 

13 00 

HHS Region X BEOC (WA) developtig regisoy4oi people who were exposed. The i^iency tor toxic 
$i^bs(dr)ce$ andd«ease registry (ATSDR) esnmaied 120.000 exposed people. Reg<ori x REOC{WA) 

OeMves this is ggibablY too hgh 


Data Colleetor Log 

REOC 

WA 

13-Mr-03 

13:00 

Incident site upAb Wr^fiEOC; 21 dead on site, infured 51 Red. 43 YeMow. 9id 45 Green: Workng wsh 

Seattle EOC to JlEdate nyfi^gs. 


EOC Supervisor Log 

WA Slate EOC 

WA 


13:05 

FBI determined matffufei went oH accidentty: may be some other targets or explosives enroute 


Analyst log 

FSL Conference 
Call 

il'. 

i3-Ha7-03 

13r07 

Director ChicagdOEMC made big amouncement - Oedarelion of Slate ol Emergency m CIveago 
recommended; CNcago nil order sheber*tn*place: Chicago Law Department says: dsciaraiion ol smsrgency 
gives authority lo lake necasssy acxions immediately. Press Conference wiH make announcemenL 


Oala CoHactor Log 

Chicago EOC 

IL 

13-May03 

issjs' 

IDPH approved memo descnbmg treatment guidelines 


DataCoHactor Log 

SpringlieU lOPH 


T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reconsin>cii<>n 


DRAFT 

FO R OFFIC I AL USE O N LV 


Page is of 29 

















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DRAFT 


7/17/2007 922AM 


Venu& 

Date 

r£DTl 

Tima 

rFDT^ 

Dascilptlon 

Analyst Comment 

TypealOettt 

Source 

Omanizatton 

lA 

19May-03 

13:20 

From DHS lidson to SIOC: NRC reports employees o1 a nuclear fadMy near Chcago »e caMno in sck. Al ot 
lha ampicyaaa had aoandad iha Chicago BlacKhawka game on May lOdt. The Blacirhawka played 

Vancouver In sMitton 10 peioarv of the NRC Aegion III staff called msK*. 


Data Coitoctcr tog 

FBI SIOC 

IL 

13*May-03 

13:20 

CFO Cniel says. 'Field tasted al Ol-late. Linkx) Stabon, and me Lhvted Center.' Not located any devices: wM 
send swap sampte to iDf^H lab for culure. Swabbed HVAC syetem and common areas. Samples lo be sent 
to IDFH laboratories, 46*hour turnaround. CSTs asked to be avaSable to come in and sts^nrli on stand-by 
basa right now. CST has relocated from Peoria to College of DuPage. 


Daia Collector Log 

Chicago EOC 

IL 

13-Ha»^)3 

1320 

Chteago COC talked wHh IDPH laboratory: They feel mac outoreak sliyted on Mother's Day: haemal uni ran 
fiekJ tests, these held tests compromised by good housekeeping. Also. 48*bour turnaround lor samples can 
be reduced to 3 hours. 


Dal CW—Qf Log 

•l. 

Chicago EOC 

(L 

13'Ma7'03 

1320 

IDPH lab lold mat HazMal would orgarc# site chedts but based on etoes ffius far sotra hKs aerosol 
eitposure. IDPH lab advtpng HazMat lo look for posstJe devices and to coded perhaps Me samples. 

HazMal babeves based on elues/don i ei^ed to 6nd anylNrg • wil sample both enofe of venelalion syetem 
for residual maienal. WII not do field ar>tfysi6hMH send samples direct lo lab. Interegency learns enH scour 3 
srtee tor davtees 


□au CoUsDlD' log 

IDPH lab 

WA 

13-Ma»^]3 

1320 

Federal JIC {WA) deterrrvnes Ihai VNN put oui erroneous informaBon: VNN annourwed that OHS was 
provkHng Prussisri Blue at reguesi of state, but stale did noi request Irom Oak Adge; Oak Ridge 
automancaiy bnngs 4. 


Daia Coiiecior Log 

nIIC (WA) 

(L 

13-Mfiy03 

1321 

Cook Courtly Epidemiology field learns are oul and sendmg case repons lo the stale 


Daia Coildcior Log 

CCDHP 

lA 

13-M17.03 

1321 

HHS ASPHEP wants papeiwork tor declaration of Public iiaaim Emergency ready for me HHS Secretary to 
sign during OneAng wHh PreaidaN. 


Daia Coliaclorlog 

HHS . see 

IL 

13-Miy03 

1327 

lOPH lob reporting Versirha pesoa positive samples to lOHNO men to IDPH Springfield. 


Daia Coliaclorlog 

IDPH lab 

II. 

13May-03 

13:2$ 

IDPH receives conlirniation from lab - PCR lasis eompiited: positive for Vpesiis |3 paiigntt) 


Oala Coilaeior Log 

IDPH 

IL 

13MIVH33 

13:30 

lOHNO 'KwlvM contifmaHon Irom Chicaga >OPH lab poativa Hx (lagua I Ta's.ws caaM ) ius£<5 on PCR 
taal ol 3 (pacimana Irorn EMi^a Haapnal. No praaa rataata |ia<! 


Daia Coliaclorlog 

lOHNO 

IL 

13 May-C3 

13:30 

IL Governor declares siais ol smergency, reouesls adivalion of the SNS. mobifezes lEMA 6 (OPH. 


Data Collaetor Log 

Lake Counry EOC 

lA 

13May03 

13:30 

HHS ASPHEP Baaed on ma evoknng numbers and a conference cal with ihe OHS Secretary, lha Atoeaa 
should be sssumed to be piegue and intentionally reiaasad. 


Daia CoileaorLog 

FEMA HO EST 

IL 

13-Mt7.03 

13:34 

Chicago EOC recervad faxes from EMNei Emergency Uessaga regarding adirebon of Sniegic National 
StockpKs. 


Oala Collaclor log 

Chicago EOC 

U, 

13-May.03 

I3JS 

IDPH aciivatas Phase II ol IL Emergancy Madcal Oisasier Plan kn re^naa to Governor's Emeigency 
Declaration 


Daia Coliaclorlog 

Highland Park 
Hospilal 

IL 

13-May03 

13:36 

Plague confirmed • gram (•> rods 


Data Coilaeior Log 

Sherman 

IL 

13 May-03 

13:40 

Elmhufsl Kospitsi rscerved lax from Good Samaritan Hospffal insiruding iMm to comt4eie the Phase 11 
worksheet. ^ 


Data Coilaeior Log 

Elmhurst Memorial 
Hospital 

IL 

13-May-03 

13:40 

IDPH ootHked Ingalls Hospital of coQeSS (Phtae II of IL Eme^ency Medial DiBStsr Plan) 


Data Collector Log 

Ingalls Hospilal 

IL 

13-Ma7-03 

13:40 

Nortfiwesterh Mamonai Hospital and ihel/hivcrsrty of ChicavO'aasocfafed hospitals activeMd Phase II of IL 
Emergency Medial Disasier Plan 


Data ccHactoi log 

Uaeonte ER 

(A 

13'May-03 

13:40 

HHS ASPHEP ask< COC ID Issk al vDfltllaiastf pan d lh«r n:aBH2alion wawgy. 


Data Collector Log 

HHS -see 

lA 

13*May-03 

13:40 

HHS see tasking ASPA to draff taking portsiegardfhg sheHer-tn-plece, clarifying ihal (hey are NOT 
rscaafflendtog sheltenng>in*place nalionwldo 


Data CbllBclor Log 

HHS -see 

1A 

13-May-03 

13 40 

BnMh CgUEIkft $ CDC confirms pneumonic uncorfirmed reports say mat el of (he sick people were 

on Air Canadftdiight 783 from Chicago. Legal vgp confirm and report back to FBI Chcago 


Dale Collector Log 

HHS -see 

lA 

i3'May-Q3 

1341 

VNN report: DNi Secretary, on phone interweiv. was asked what should people m Code Red obes shoukf do* 
-urged people l^w^inimize public aclivliy and keep cMtffen a( home. HHS ASPHEP recornmends that people 
Take a snow daif^ 


Situation Report 

DHS-CAT 

IL 

1»«ay-03 

13:45 

Loyola IliiiiiM iiiyfiliulK il fielTi actrvaied Phase II of IL Emergency Medical Dosster Ptsi 


Data CoHeelor Log 

Loyola Univ. Medical 
Center 

II. 


13:4S 

Sherman htosortataeMeO Phase II of IL Emergency Medtoal Disaster Plan 


Data Coiiecior Log 

Sherman 

a. 

13-May*03 

13.46 

Declaratiort of dipster sfgned by Lake County Board Charmar^ 


Oala Collector Log 

Lake County EOC 

lA 

13*May-03 

13*49 

Cossi Gua;d closed aM vessel lraff« in (he Port of Chicago. 


Shuahon report ffom BICE HQ 
Reporting Center 

DHS-CAT 


T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reconsin>cii<>n 


DRAFT 


Page 16 of 29 





















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7/17/2007 922AM 


Venu& 

Date 

rfiDT) 

Tima 

lEDT^ 

Daaciiptlon 

Analyst Comment 

Type al Bata 

Source 

Orfunb.etinn 

IL 

13-May03 

13:50 

Lahe Courify £OC PIO tells ihe Lake Couniy P\0 al Ihe IL JIC not te issue a press rotcase o( dedaralktns of 
emergency unN all counties release a declaration 


Data Ccriiecfor Log 

Lake County EOC 

n. 

i3-MayC3 

13:51 

Univetsity oi Chicago called to notify South Shore Ho^Mtal of acSvabon of Phase II of IL Emergency lutocical 
Disaster Plart . Phase II worksheet filled ou by ED supervisor. 


Data Collector Log ' 

South snore 

(L 

13-May-03 

13:56 

VNN report (DPH says probably plague 8 Canadian otficals ccnfirm plague 


Oala CoHacior Log 

AAC Of Greater 
Chicago HQ 

lA 

13*May-03 

13:55 

CDC issues Health Advisory ff3, suspect pneumonic plague cases repohed in IL 


osweatmuirLog 

FBI SIOC 

lA 

13-Ma7'03 

13:56 

HRTieOC Osployirem approved by FBI HO in accoidance wan HRT daployinani diroctives. 


Reg on X ROC Input to EP8R 

SiTusTion riQfl^ 

0HG1H$ Center 

U. 

13*May03 

13:58 

VN N report : DHS Secretary terms prelminafy diagnosis of symptoms as *pl8gue* 


Data collector Log 

Karw County EOC 

IL 

13'May-03 

13:59 

AAC of Greater Chicago observes DHS Secretary on VNN announce ffi« IDPH has a prelirrwary finding of 
ptague-Nke iHness • urges residena to restrici movement and slay inskte. Vancouver has confirmed plague 
so Chicago rnusi work on assumption of plague. ARC atfTMr>etr8Bon tkseusses the mematch between the 
information m the Sec'etarys speech and other sources confvmng ptsgue. 


Data Coliaclw Log 

ARC - Cnicago HO 

(L 

13-Ma7'03 

14:00 

200 National Guard personrtel raguesied lo assist lbs futodical Esanner in morgue dudes: report fo Poice 
Areas Centers i through 5, Pvst Pokes Distncl. O’Hars Airport. Mdway Airport 


^ National Guard Request, Police 
Deparlmeni 

Chicago DPH 

IL 

13-Mey-03 

14:00 

VNN rtpori: DHS Secretary armourKes plague n Vancouver and also probably in Chicago: recommartds 
public trsat if as a ‘snoiMlay* 


Dele CoiieetorLog 

IDPH 

IL 

13May03 

14:10 

IDPH Spnngfieid: Recotnnier>d IL Governor request Nalionaf Disasier Mescal System {NOUS) and OMAT 
(naed epidemioiogie spaciahsis to aasrsi with (Mease invasiigations). 


SEOC Event Log 

IL State EOC 

IL 

13-MBy-03 

14:12 

VNN report: 14 confirmed dead In Chicago 


Daia CollaclorLog 

lOHNO 

IL 

13 May 03 

14:17 

IDPH arranging web poslir^ of memos on trsatmem and praphytana 


Data Ctf lector Log 

IDPH 

1A 

13-Me/-03 

1422 

HHS confirms 14 dead in Chicago from SARS*tike Hnass 


EP&B aotMiy log 

DHSAiS Cantai 

IL 

13'M9y03 

14:30 

PBl Chicago con1lrmk>g Pr>auniortic Plague 


Data Collaelor Log 

Chicago EOC 

WA 

13-MBy03 

14:31 

DHS la workir>g on a PRMAC transbon plan lor lead to shift to EPA from DOE 


Data collector log 

EPA • RCC 

IL 

13-May'03 

14:38 

\ 

Du Page County DPH: Plague identified, nen slaps are to gat «n1bBtf Boh dui fifU do ccniact iredng 

- 

Oala Collaelor Log 

DuPage County 
Health 

WA 

13-MB7-03 

14:40 

WA SEOC boking lo verify casualty numbers from ineKlent site, nufober *iaallla V putting out « dtfferem 
than what King Courtty a puiong oul 


Data CoHadO'Log 

WA Slata EOC 

lA 

13'May03 

14:60 

CDC EOC: Seenw updaia - Two conlltniad lalalim: 1 .200 people evecuawd. eopdetomanmialed. 4i n 
cdlKal condnon in area hoapWa 


Data Coilaetor Log 

CDC EOC AUanta 

WA 

13-Ma7-03 

1S22 

Unified Command Brief; Hazmat leems following ERT m rubble. Cadaver dogs on site, Evider^ colecbcn 
to begin soon, FEMA. EPA. and OQE soil m support After botfies have be^ cleared, wifi shift locus to long 
rang# remediaiion 


Dala CollaelorLog 

ROD alia 

lA 

13-May03 

15:06 

Faderal Radtobgicai Monrtonng and )feussiimii Cww (FRMAC) has athnsBtmai may compiewd Mnal 
measursmanis arb ground samples oi radiation. Tb^radMon does not pospen immediaie threat to He or 
safety; peopla wKhin Ihe shetTer m place area could sUqr in place for up lo a year without excaetkng EPA 
protective ecHon guidebnes for radiation dosages: PPBhas already evecuaied the Federal fac44es ttrel had 
sheltered in place. OSA 8 FP$ iM developa IMf people that w«s shefteied vi the Federal buideigs as a 
precaution for future medical review. 


Situation report from BICE HO 
Reporting Center 

OHS/CAT 

lA 

13May-03 

15:09 

CDC (NCtD) receives nollficabon horn ChkcaKdf eonfirmabon of plague 


Data Collector Log 

MCC 

IL 

13May03 

15:11 

ABlIBlv^OOunty begins distiibtAon of thee pnawpcoiftical stockp4e based on iSovamor^ request tor SNS. 


Data Collsctor Log 

Du Page Co. 

WA 

13-M^3 

^ • ■ 

15:15 

News reieautpm KC Regior^al JIC: The SiaT^^partment of Agncullure has aiv>our>ced that precautior^ary 
measures areBppommended for the areas: East of the King County 4(ftsap County border between N.W. 

85th Street andi.W Adnsra) Way: South and west of 85th Street to 24lh Aver>ue N.W. to 65th Avenue 

N.W, to l5Di Avt^pue N.W. to Highway 99 to Denny Way to Herstaie 5 to Interstate 90 to Highway 900: 

North and wesi dt South CcKitibid Way from Highway 900 to iSih Avenue to South Nevada Street lo4ih 
Avenue to DawaUi Street toH^hway 99 to Spokane street to S.W. Admirel way to the KmgrKtsap County 
Border. ^|iii i ifit iin'i imm— yliiiiiitiioPi" 'i ini inili IIk Inllnwiinj Avoid purchasing or consuming products 
stored in open alpmvt^^ifter 12:10 pm on May 12. 2003: Fnirts. vegcKdiles or grain sfwukf not be picKad: 
Shell fish harvss9bllfll^?:t0p.m. on May 12. 2003 should not be harvested or eaten; Agneuiu^ 
products should I^HUftranspoded uncovered throu0) the advtsory area: Pets should be restricted to water 
sources lhal arefiprered or are from enclosed underground storage. 


Press Release 

KC Regional JIC 

■1 



CDC EOC confmTHng 3 oases of plague m Chicago, confirmed by PCR fiom CRN lab n Chcago, 

a 


Dala Collector Log 

CDC EOC Atlanta 


T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reconsin>cii<>n 


DRAFT 

FO R OFFIC I AL USE O N LV 


Page 17 of 29 



















7/17/2007 922 AM 


Venue 

Date 

ffon 

Time 

fEDD 

Description 

Analyst Comment 

D. 

13-May03 

1620 

Elmhurst Memorial HospHai receives fax from fOPH regarding signs taid symptoms of infeclious doease 
trend beginning to appear. Emeigency managemeni coordinator and charge nurse notified by EH staff who 
also notified infecbous control nurse. 

ti 

WA 

13May-03 

1520 

Mayor's Oectsion those east of lS can leave home wth certam precauttonaiy measures, sate tor them to 
resume dally aclrvibes, sbl need to be monitored, send message that Ihey shouldn't eat home grown 
vegetables, let Ihetr kids play in the dirt, and avoid dust (hose west of l*S wfl be relocawd tor 3 days. Very 
few people remain West of LS since 1200 people were evacuated last nighL Use ouidialer lo oontad them, 
get them out with reception pomis, and decon shelter <ui> by PHSKC. Posstoftty of hof spots so they may 
need to be kepi for more Ihen 3 days 

\ 


Elmhurst Merronal 
Hospital 


WA 

13May-03 

15:30 

Meeiirtg between HAZMAT IC arto CST cominartoer< inJoatton « that C8T « no longer required. CST to 
redeploy. 



WA 

13May03 

15:34 

Agneutture advisory Irom WA Depl. o1 AgrtouRure: The toUowing precautionary measures are recommended 
m the affected areas: Oo nol purchase 6nd or consume produces Ihal were stored in opervak markets after 

12:1 SPOT (15:10 EOT) on May 12 Oo no pick or harvest tiults, vegetables or grain. Oo not harvest or eei 
shell fish harvested atler 1 2: 10 POT (1 5:10 EDT) on May 12. Do not transpon uncovered aghaMiral 
products through the a^aory area Hesinci pets to water sources ffiat ere covered or are from enclosed 
underground storage 

\ 

i 



WA 


IL la-May-OS 


WAOtsasier r«ld Otiica scheduM w opdo May IS 


Cook County Hoaith Dapanmant requaais SNS: formal raouasl to ba mada within aavarai mtnulas 



IL 13-May03 


Cook County Board chairman argns loini Cook County and Cnieago amargancy deolaraaon. 


-a 


lA 

13Msy03 

16:00 

DHS ALERT AL-03TOPOrF2M. 'The Secretary ol OHS. In coflSuRailon wRh toe inteK 
the HomeianQ Security Courtol, raised the nabcnal threat level to Code red nationwtoe j 




13 . .Federal Oepertmenis and Agencies, and State and local auihonttes. are directedfl 
implement p'otecllve achons identified In Operation Uberty Shield. . .* 


li 



IL 13*Mav<03 


lA 13May03 


Haws Raiaasa: Tha City ol Ctucago daciaraa a Staia of Emarpancy dua to Pnaumontc 
probaM ralaaaa aitta of Oiara Airport, Urntad Cantor, and Union Stalion. Cheapo Fira 
datarmmad ihal no lurihar releaaaa are auapactad. 


City of emcago raquasts push pack from Straiapic Nallonal 



8 8a, , 








ICE SKuation Command noUliad its field oHioas ihal the Bnteh Cohjmt 
l3*May*03 16:21 confirmed (hat indrviOuala adminad io lha Vancouver Qanaral HoapAal 

pnaurnonie piagua. 


1«'57 VNNt«pon. Canada MMlih 
13-Mai-03 l»i7 curranBUtacKInaindlvklusla. 


Ar Canada ni9M 783; 


IL 13'Mav-03 16^8 


VNN lapon. rapid reaponsa laam nas 
Untied earner end OXata Airport Inu 


' UnHed Canter and O’Hara Airport inteuMunal i 

l3'May03 16:32 Pax masaaga lo Chroago EOC' IL GovantiafSikincas lOPH is 


but not contiimod tarronam. Fax sent out to provide 



IL i3May'03 16:33 


IL 13*May-C3 16:3 


Fax racervad at CCDPK • IDPH Lab confi 
tor lUHNU 



. 2003 showed an mcreasa In raspxaiory tract 
y 12 and incraaSMig through May 13, 






16:45 WASEOCrae 
16:50 Fax of IL Cover 


OC received official fax from IDPH • PCR confirmalion of pneumonic plague 


EOC: confimng 20 dead and 117 infixed 
y dedaratiof) arrived at Lake County EOC. 


BEa^^ 


16:54 Truck wrTh Cobal60that was repohed missing boated, cargo intact 


Dale CoUaeiorLog 


Dau Coiiaciortog 


WA State EOC 


Chicago EOC 


Daia Coiiactor log 



Oaia CoJbeiorLog 


Oaia CMbetorLog 


Data Coiiacior log 


Chicago EOC 


St. Joseph’s, 
Chicago 


Situatton raporr from BICE HO 
Reporting Canter 


Daia Ooiiacior log 


igi^CcNcagc • Ureon staeon. 


OmiM inodam a«port 

DijPaja County 
EOC 

' confirmatton of Plague 


Daia CoHamorLog 

Chicago EOC 


Oaia CollactDr log 


Dale Collaeiorlog 


SHS Operation$rCenter has not reeaived any repesls from g>e IL Governor br the SNS. even though the IL 
Governor already arvwuncad on VNN (hat he’d requested SNS 


R « not de» from ihe Situation Report when Ms 
but H was no later than 17:00 EDT 


Data Colleetor Log 


EOC Supervisor Log 
Data Collaclor Log 
Data Collector Log 


Situation report #4 


DuPage County PH I 


WA Slate EOC 
Lake County EOC 
USDOT CMC 


SNS Oper^ons 
Center 


n(y EOC: Cook County has filed arxl recorded a efisaster dectaralion to ensure authonzalion of 
emergency procedures 


SEOC Event Log 


T2 AAR Annex A - T2 MASTER RECONStSuCTION 
T2 Reconstruction 











FO R OFFIC I AL U SE ONLY 

DRAFT 


7/17/2007 922 AM 


Venue 

Date 

/EDTl 

Time 

lEDT^ 

Description 

Analyst Comment 

TypeeliDettt 

Source 

OmanizeUfvn 

WA 

12Mdy-03 

17:05 

Evidence coBection at ihe ROD site: RDO ste broken ireo 4 quedrants lo eetabish radtotogical reading per 
quandrant EPA wil tonow FBI on site, inen SFD «iil Mow - 2 tevns ol 2 lo mark GPS coordmates. 


Data Collector Log 

RDD sits 

0. 

13May-03 

1721 

Lake County EOC recetved tax Irom H. JIC stating there wll Oe no press release retening to county dSaster 
declarations. 


Data Coliecior log 

Lake County EOC 

lA 

13May-03 

1720 

A Task Force of 250 Army National Guardsmen has been activated and wil be deployed « 06 00 POT 
Wednesday morning ^ 'dteve Washingion Slate Pohce Iroopers mamng road dosure checkpomts. 


FEWA NEOOEST 

0 MS/CAT 

lA 

13 May-03 

1720 

All air traffic mlo O’Hare Airpon has been suspended by order o< OHS. ri coordinalion with FAA vid T5A. An 
exception was made lo accommodate the trvtspod ol shipments from ffte SNS. 


F^MA NEOC-EST Sjtualion report 

OHS/CAT 

lA 

13-May*03 

17:30 

HHS Secretary declared a Pubfec Health EmergerKy in the City ol Chmago, alowmg the department to 
provide Federai health assistance under its own authority. 


FEMA N EOC EST 

DHS/CAT 

WA 

13 May-C3 

1722 

VTC discuseion across EOCs regarchng confhctn^ niormaiion over road openings: WA State Poke* says 
highways are open, but WA DOT has ihe aulhoety not the police. WA DOT wants to wah unii conftr mason 
from WA DOH that cTs sale 


Daia Colleeior Log 

KC EOC 

WA 

13-MBy'03 

17:35 

FBI reports that the Seaffle port has reopened 


Analyst log 

wKX^CUG 

ll 

13-May-03 

17al0 

Chicago EOC obtains Chicago DPH's own sioekp4e: ctMe set up at Wesisde to prophylaxis Chicago DPH 
staff; Logistics chief to epidemioiogy * EOC staff have PPE 


Dala Collacli)' Log 

Chicago EOC 

WA 

13May03 

17:40 

DMORT arrivod at lha incidem aKe. A meeting with FBI, SFO HAZMAT. and DMORT ensued to deiermine 
when and where the OMORT should ael up their aqu«meni m the hot zone H was deoded that in about an 
hour. FBI would allow DMORT to set up alter FBI was ftn^hed. 


Dan ChUaciwLog 

RDO sAa 

tl 

13'Mly'03 

17:45 

VNN report H$A$ rarsed to red tor erwre nation. al ffaneport m Ctvcago dosed. 48 hour hgUo aP putFc 
nameriivi 


Daia Csllsctor Log 

IDPH 

IL 

13-May-03 

17:47 

VNN report CDC ennourices rreelth eierl In Mnots 


Daia Collaclor log 

ILVCC 

)L 

13-May-<13 

17:49 

Signed request for NOMS snd OMAT sent to FEUA Region V ROC 


SEOC Evsni Log 

IL Staia EOC 

11 . 

13'May-03 

17:60 

VNNrepon: DHS Secretary snnounces plague in Wnote, ports, arams. end xports sll doead: urge people to 
stay In place; HoHywooO celsbnoes says slay in place 


Daw CoHaoloiLog 

ILVCC 

lA 

13-May-03 

17.60 

VNN press conference with OHS Secretary. HHS Secretary, andjeou FBI represeniative. OHS Sectetny 
confirms plague in (linoks: announces UN Invocation of UN Charier Aiscle V. announces elevation of HSAS 
level to Severe (Red) naiionwtde for 4$ hours, assodales (he Seatle RX end (ha ui no« plague with 

OLOOO, and says lhal h# has sskeo Mayors and Govamors lo vnplemeni Operation UberN Shwid hke 
proteeiive aeiions 


Daw Coliactor Log 

MCC 

WA 

13-May«0d 

17:67 

Seattle EOC evscuahon overview impieirienting plan to lei people Eastt 1*5 ttnve home^ffUiUf'ucfion 
on how lo do so. West of 1-5 we wil use the same protocol as lasi nigh^ estate aH people eiexdt/sion 
area. Military wM be providing bus drivers for rrwro busses WW use ouUlBlerlo cel all locaf residents 

Pecpis will be loid to take possessiorts lor 9 days. Leave pets withihree 4Br8 of lood and water. People wH 
get screened at the airporl: il will beeotuntary screenmg but we highly receipt nded they get screened. We 
will not mandale Ihe evacuation. espeoaNy Kx seniors. Buses wdl run from 442 pnviocay. We will evacuate 
m an orderly manner so lhal no one %oul stafVing and waihng for a bus lo cOBMlong. SPDwilmorwor 
pertmeier and keep out strays. 


Daw Coilacior Log 

Saatila EOC 

IL 

13-May-03 

1820 

Chicago EOC advised that SNS had been activated surveillance staff dMcuss cknc staffing • decide to use 
existing model with plans lor up to 8 disv^pon sjiar. 


Data Colleeior Log 

Chicago EOC 

IL 

i3-May'C3 

1800 

IL Governor sent a latter ttvough FEMA Regvi V requesting a Obclaralion of Maior Dsaster under die 

Stafford Act 


SEOC Event Log 

IL State EOC 

WA 

13-May-03 

1820 

VHhfnpiiil. DHS Secr«(a'y announcing HSAS raised U naUonMde RED. P60. who ia now al Ihe WA 
'SEOC. iusl recicves confinnalion that HSAS ralsaO lo red. 

Tills even occurred between 1520 and 15:30 POT0820 
and 18:30 EDT) 

Data Collector Log 

WA Slate EOC 

1A 

13-Ha»-03 

18.00 

Reglprmi FDAii#ector reports restriction ol aB food supphes wChin plume area 

The erakialion team could not confirm when this was 
implemented, but H was no later than 1820 EDT 

OHS CAT Briefing or the Federal 
Response lo Seanie RDO 

DHS-CAT 

WA 

13-May«»r 

TStM 

USAR learn arn^jpg now arKtwH be operalionai al 2020. Another nobonsS team will be amvng al 0820, 


Data Colleeior Log 

RDD Site 

WA 


18:10 

Seattle EOC gra&iatfy-SbOcdung contammaled zone based on new *analylic information* 


Data Collector Log 

KC EOC 


13 May 09 

18 17 

KC EOC poicy wants a copy of (hat press release - we want confirmason before * we roH lhal hand 

grer>ade out inmha EOC*. 


Data Colleeior Log 

KC EOC 


T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reccnsirveti&n 


DRAFT 

FO R OFRC I AL USE O M LV 


Pa9@ Id of 29 













FO R OFRC I AL U SE ONLY 

DRAFT 


7/17/2007 922AM 


Venu& 

Data 

IfiDTl 

Tima 

IFOT^ 

Description 

Analyst Comment 

Typa al Bata 

Source 

OroanizaUrm 

WA 

^2 May-02 

18:20 

SeatOe EOC Policy room: People come in al alarmeO because DHS wants to go to Red nation w»oe. No one 
knows wNy but that requ)ces Ametcans lo stay home lor 48 Aouis. The Mayor was not asked about this and 
Tn« goes agamsi Ns plan lo reium lo normalcy. Conlerence in EOC Directions ofTice on about statement. 
Whyjs DHS making Itws statement without contacbng stale courSyoratytopoflioals? Reconunendabon w 
that we ueai lh»$ as an unconiirmed rumor and get them lOHS) lo back otf. 

This event occurred between 1520 and 15:35 POT (18:20 
and 18:35 EDT) 

Daia Collector Log 

Seanie EOC 

WA 

13*May-03 

18:30 

FEMA Region X ROC deputy director - directing sia/l lo adivaie ihev *RED* plans and procedures 


Oala Collector Log 

FEMA Region X 
ROC 

WA 

13May-03 

18:30 

WA EMD Director requests guidance Irpm DHS Secretary on steps to lake when HSAS raised to RED. We 
need hard copy of recommended restncbons form DHS, 


EOCagamsor Log 

WA Stale EOC 

WA 

13*May-03 

18:31 

WA OOH determines Ihel t-5 can be reopened; WA DOH passes information lo WA DOT 


Oala Ccrifector Log 

WA Stale EOC 

lA 

13May-03 

18:40 

SHS Operations Center received request for SNS and approval lo dspfoy i push-pack to Chicago 

Fofiow'ip calk by analyel eentirm ttie Ocpioymeni was « 
approved by FEMA Diwtor, EP 8 R. OH& in ccnlerenee 
with COC Deputy Chief WStaft ^ 

Stiuation Report 

SNS Operaaons 
Cenier 

lA 

1 3-May*03 

18.53 

HHS/SCC conference cal - key diacussmn poinls Prussian Slue avaitsMity end Ihe lack ol specific 
guidance on large-scale use: pnmaniy used with peopis exposed after they are decontaminated. DMcvfty of 
assessing kiiemai exposure wHhtn individuals irifured m Ihe biasi. Pubkc Heaiih offtosM recommend ihai 
travekers be atened end a *lever watch* msiNuted for those peop4 poienuiy exposed to plague. Chicago 
asked non-essential employees to stay home. Thai might mpact avaHabifety ol healthcve personnel 


Oala Collacior U 19 

HHS 

lA 

13May03 

19:00 

Memorandum tor the Presideni: Request for an Emargency Declaraftcn for the State of llinots From:Uf¥ler 
Secretary. EP&R (Michael p. Brown). Event: On May 12.2003 Oovemor Bl^cesvicn requested a maior 
disaster declaration due lo an outbreak of Pr>eumor>c Plague in the Cfty of Chicago (Cook County) apdlou 
surrounding counm The Oovemor does noi spedfy a spacHie type ol assistance bu) raiher raqueets 
lupplemenial Federal assistance lo preserve Ives and property and protect pubfic peace. and safety. 


Data Collector Log 

CDCEOC Allanta 

IL 

13*May03 

19:18 

Director of Chicago OEMC Dr>efing: Press release provided decfaring State of Emorgency; C *08 nq sctioob, 
O'Hare and Midway Airports are closed by DHS Secretary. SNS esomaied to be airrvtng at 10.00 CDT 

1 1 1 :00 EDT) on May 1 4 at O’Hare Airport w«h 1 milion doses for hrst resporders end incs# first affn<(cd • 
this IS enough meds lo irsat a smgie person for a week and is enough for CNcago and surTouaaiQg£MKiws: 
there wiD be a lag period lor breaking down SNS and tksinbuoon • hopaluby, w4l begin the (ksirtettaftcm May 
15. 


Daia Coileaor Log 

Chicago EOC 

WA 

13May03 

19:20 

WA SEOC reviewed air space cloeuree because ol RED aten siakis. decscn was made ihai rest^cHcns 
would tatftain in place 


Data Collector Log 

WA State EOC 

WA 

13-May'03 

19:20 

Road status: 1-5 raopened. bul not ent io downtown Seattle or Weal 4^ of SS: l-9g. SR 520. ana Weal * 
Seeille bridge ak reopened : SR 99 closed unlll sampling a corrpleted.’EIS'Jfts espcwl m? houri. 


Oaia Conacior Ug 

WA siata EOC 

IL 

13 May 03 

19:25 

Chicago EOC repons EMS volume mcreesed by 10%; 8 ready reserve arga::iances placed n larvA^e: privsrte 
ambulance comractor noehad lor poss4)ie aciivaiior>; 15 spare ambutojicosMi require waiver from IDFH io 
piece in service. 


Daia ColleciorLog 

Chicago EOC 

WA 

13-May-03 

19:30 

WA SEOC News ralaase. Washingtoo Stole Femes wd resuma mee tufi pii4c&orvice schadule baginning 
el 4:30a.m.on May 14. with some eiceppons 


News Release 

WA Siata EOC 

WA 

13*May03 

19:42 

Deputy Mayor adirtses Mayor of 1*5 openeig^ has a>reddyl4cen plaee. Pubfic message lo iridicaie 

SiQnifi^ delays: ancouiaga public eanspWBn. 


Data Collaclor Log 

RDO Site 

WA 

13-May-03 

19:54 

SFf>9NAT arrives al suspacled GLODO salelBuse - 


Daia Collector Log 

RDD Site 

WA 

13-May*03 

19:55 

At 1500 hours, Wdshtogton Departmern of Health provdedprefemlnary lab tesls. These results showed ttie 
presence of lour isotopes: cesiiun 137. plulDTHum 238. ptuKinum 239 and amerksum 241 . Soil samples m 
being lorwardedio DOE for more Piorough analysis. 


Intefligerice Summary Repoil 

WA FBI Field OKice 

WA 

1>Miiy-03 

19:58 

SPO SWAT eorrgaeies lakedewn of suspected GtOOO sale house 


Daia ColleclorLog 

RDD Site 

a. 

13 May03 

20 00 

lEMA reported Mdfipy and O'Hare airports are closed by DHS: cunous H Ameican Red Cross wiH attend to 
needs of strancKAtt dveters 


SEOC Even! Log 

IL State EOC 

WA 

13*May-03 

20:16 

SPD fQ-etates crime scene pait is done so SFD is in charge. 


Data Collector Log 

RDD site 


T2 /lAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reconsi/uciien 


DRAFT 

FO R OFFIC I AL USE O N LV 


Page 20 of 29 













FO R OFFIC I AL U SE ONLY 

DRAFT 


7/17/2007 922 AM 


Date 

(tPTl 


Tima 

IFPT) 


Description 


Analyst Comment 


WVA i3*MayC3 20:17 SFD roQuasiecI mutual aU tor HazMst to contiiuie recovety opeiations 


1 2-May-03 20:18 KC EOC poltoy room receives repon that 1-5 and West SearUe Bridge win reopen 1600 lonighL 


13-May03 2i;05 


'Pte NRC reponed yesterday evenmg al approiimaiely 1600 (WST) the Palo Verde Generaeng Slason 
received an anonymous Oornb threat agairtst the faciity. ^le caler said the enviioiYnent has bean aamaged 
enough ihrougn radialion poisoning and he and AHah wH lake revenge. The eaNer dto not daim lo be pan ot 
any terrorsi organtzalton and there is tio evidence to corroborate the threat. 


WA 13*May-03 21:14 


UnHied convnarrd meetmg: 1) FBI advtsed Ihev assets are poll e d out. 2) FEkM advised they are in charge 
under FBI: PEMA has grven command to locaB * SPO and SFD have unded command now together. 


WA i3M6y-03 22:40 


King County ExecuTve in keeping with DHS Secretary request tor ak people to remain al home made the 
toltowing announcemenrs regarding County sarvtoes elfecttve through Thursday, May IS: Essential County 
services will be maintained such as public healto and salety. however, only essentai personnel will be on 
duty: The District and Supenor Court Juoges have suspended al scheduled hearingB al aM court toc M ionis 
Scheduled Jurors should rtw report unW further notice. The RegtorW Justice Center in Kent Jal DMston wil 
cominua as 4 has this week, Metro Transit wil be operating on a modihed hoWay schedule. The Downtown 
SeaiBe Transit Tunnel will be closed: Al King County pansier tocitoes and Cedar HHs landlil wi be cloeed 
until lurthar notice. Reskienis that have garbage should bag their garbage put m a secure place unel sennce 
reeumes: Kmg County is asking aH essentiei personnel to report tor work. King County employees should 
check with Their supervisors. Updates on this and otoer intormailon can be tound on our Web s<a « 
vnvw.meTrokc.gov or by letening to local news. 



lA 

13-Mlly.«3 

32:50 

StOC: iKOXimend lhal ClHcseo should sisnd-up a JOC 


DaU CoHadliv Log 

FBI SIOC 

lA 

iaMay03 

22:50 

HHS convenes Emergency Policy Suppori Group. 


Oala CoHaeiorLog 

FBI SIOC 

WA 

13 May 03 

23:22 

WA SEOC received cal from Seattle EOC that field play conctodad 


Daia CoSeelor Log 

WA State EOC 

WA 

14-MBy03 

02S 

Consider this s format request from the Stale of Washngton CRy of Sealile is requesungl^^^t 
prepos<Qoned equipiitont package being held at Boaing Field by DHS. 


Email 

WA SiaW EOC 

lA 

14Msy03 

2;5S 

HS Cenier report irom FEMA EST. The FEMA EST is requesting gutoance as to what « ihe eitoM^^^i 
the States under treat condilion *Red,' 

W ^ 

PanodCovarM 0200 May 14. 2003 M 1300 May 14. 2003 
PDT 

br 

Region X ROC input to EP&R 
situation report 

DHS-CAT 

lA 

id-MBr'03 

5:10 

PEMA ooniataric* eai Mh Ragiont K> diBCuaa numarcwa Sum fxiwF^^^hlll^uV padugas S 

Knodcoverad:0700hours EOT May 1310 1730 EOT May 
15 

EST snuation Rapon 

FEMANEOCSST 

IL 

i4.Mar.D3 

5:15 

DuPagaCountyDPHDincutauih«iitadih«rBiMMO'aniiCiioKaloA‘’>'' 


Dau Cl^MCIOrLog 

DiiPaga C«. Haaim 

lA 

14'Msv-03 

6:23 

INJECT; DOT FRA activates the RegionH FRA COOP plan m Chtcago % ^ r 


Daia Colleelor Log 

DOT CMC 

IL 

14-MSV03 

6;2S 

Phon« convaraaiion baiwaan lOHltp and IDPH par H Oo>^ pr«a raMaa*. Unaad Caraai and Union Siaiian 
was not llsraO to cloaa down • tOPHlteoirrands ihoaa vanuaa ba elosad Jail FBlLaw antorcamam 
Oatammas tarronst raiataO and marks thaea vanuas aa cnmt acana. ' 


Daia Colleolor Log 

lOHNO 

IL 

14-Msy*03 

62S 

DuPage County DPH mommg bnefing: A 15.25 COT (16^ BCII)on May 16. lOPH releasad intormsMn 
about ptogue. requested the $N$. tmd teiorijecf disktouttfiii of vtettMto thoee who may have been 
exposM, ai 17:42 CDT (1642 EDT)on Iv 13. tDlFriepOflad fl|iBHR4ontirmed. people who were al United 
Center, Union Station or OlHare on May T^br lajv may be expostol and recommended tor prophylaxe: a 
local declaraiion (S no longer needed as tha^itoe declaration Is selhoem 


Data Collector Log 

DuPage Co Health 

(L 

14 May-03 

6:40 

DuflageCouniy DPH directed the staff lo prepse tor Ihe dekvery of Ihe SNS. 


Daia Colleetor Log 

DuPage Co. Health 

lA 

14-May-03 

6:45 * 

L 

T5A and FRi^dfecuss potential rail shutdown. FRA daritias that STB ii the only authority that can shut down 
ran. 


Data Cdleeior Log 

VA Central Office 

11, 

14.Mlvie3 

9fl0 

ARC agrees to aopport sTran^V travelers with mass care, health sarwcas. and mental haalh. 


Dau CollaclDrLog 

ARC - Chicago HQ 

IL 


9X)5 

r 

DHS Secretary ijf.iaiJsi ii|iil ilii on VNN. lenor^ attack, plague contiimed. taoterronsm event 


Data Colleclor Log 

lOHNO 

ia' 

l4-May-03 

9:1t 

MST tasked to come up with recommendations tor tksposmg of eoniamtoaied botfes. COC working with 

MST to do this. 


Data Collector Log 

DOT CMC 


T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 ReccnsTrvcTion 


DRAFT 

FO R OFRC I AL USE O N LV 


Page 21 of 29 







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7/17/2007 922 AM 


Venue 

Date 

Time 

Description 

Analyst Comment 

TyiMWata 

Source 

Omanizetinn 

11 

i4.Mdy«03 

9:17 

IDPH Director auThorized cNsliiDution of prophylaxis to ftrsi responders. 


Deiajiu incioemagmrt 

DuPage County 
EOC 

(L 

l4>May'03 

920 

Chicapo DPH Sftualton report: NDMS requestsO 


Situabon report 

Chicago DPH 

IL 

l4May-03 

9:30 

Chicago DPH SnualM)r Repon. O’Hare and Midway a^poris and Union Station in CNcago have been closed 
by the U.S Department of HometanQ Security |OHS) 


Sltueuon cepon 

Chicago DPH 

IL 

1AMay-03 

9:30 

Chicago OPH Situation report: H. Covemof has recommended that non-essenaal vfortwfs n the aflected area 
stay home. Schools in Cook, DuPage, Kane and Lake counties have been closed. DHS has recommended 
that all non*esseniial large put*c gatherings be canceled. 


SSiiaiioh NpoB 

Chicago DPH 

lU 

lA-May-OS 

920 

VNN report: DHS Secretary has cioeed CHare. hWway arpons and Station 


Data Cdieetix log 

SpnnglielO IDPH 

lA 

14-May03 

9:45 

Depanment of Veterans Aflairs update to HS Center; VA has informed aN faeiUies of nerease in National 
Threat Level to RED and imtiateO the implementalion of levef red protective measures tor al VA lacilUes. In 
response to alert level RED. VA's pre-COOP leam o on alert to deploy (nooonaty) to VA’s primary COOP site 
at 1 6:00 this Wednesday atlemoon. A Secratanal successor wH be on*sfie 20 ftegue patienis presamad to 
VA Medical Center Hrte, Htnois; 10 palkencs were adnwied lo ootason beds and 10 dM. VA provided Ihe 
White House and HH8 inventory o1 pharmaceutical assets, apporpnaie for use m the ireaimeni and 
management of Plague, located in the Chicago area. 


0ai9 CsiiscWLog 

DHHS'SCC 

IL 

U'M>y'03 

9:49 

DuPage County DPH noohed DuPage County EOC lo tel hrst reeponders to come tor prophylaxis 


Data ColUctor Log 

DuPage Co. Health 

II. 

14-May-03 

8:67 

IDPH requestirig: 5 K DOT vehcles and drivers: S IL CorrecDons vetsdes arxl drivers: 27 IL ^f|i ptfteemen 
and 6 cars: and 40 IL National Guard members to be al fftt FedEx Terminal at 0>lare Arp^^Ay fOtiO CDT 
(t1:00EDT). ^ 


SEOC Evenr Log 

IL Stale EOC 

IL 

UMay03 

10:00 

La Grange Hospitil received lax from IL Govemcr wamng employees of iiijii ujjjjJWBMfcpses to staa 
home until lurihar notice. ^ 


Oaii Csllacior Log 

LaGrange 

IL 

14.May-03 

103)0 

city d cniuoo tnui down al paaaangai nnaeonalion « and out ol Chicago. kiOuding aapons^^^^^ 


Dala CUHciorLog 

FEMA Region V 
ROC 

IL 

14 May 03 

1023 

IL Governor signs 'Executive Order* considering ihks to be a poa98ShMlfohd> suspended HIPAA ano^H 
Blood 6anKs. . ahow slate to share communicable (hsease iiiformjBQ||Bn susper>ded ^ 

licensing act so that physicians can pracUce in piacas where mey ft%nOTlBI{B^aa^yarity supend legar 
constraints on other profesaonsls so lhal others can dispense iiwifiMiiiii andinBBto^^lher pla^ 
other then pharmaoss {MrlCution and admmeirabon of anilbioUcs), iL 

K 

Dale Collector Log 

Lake County EOC 

lA 

UMay03 

10:0S 

Tha Piasidani (nodonaO O'amad an anwgancy dadarawn <FEMA.a3^X^«u iBhim M ayfiTio adoaas 
tha haatth crista nlha Chicago araa. Tha dadarabon covars CooA, DuPafTrUna and Laka dbunbas. An 
PCO was appointad % 

Note; A Major Disaster Oedarauon was requested by the IL 
Governor, but an Emergency Oedarabon was granted. 

Oedaraoori 

OMS/CAT 

lA 

1 4 May-03 

10:06 

The WhKe House. FBI end DHS vt leeWng to HH8 lor leadership n oalunreublc healih message 
concerning events in Chicago and SeMHe. 


Dala Collector Log 

VA Central Office 

lA 

14-May<03 

10.06 

CDC called SIOC. Deployed SNS push^ck and re<deployed teams ^ 


Dala Collector Log 

VA Central Office 

lA 

14*May-C3 

10:06 

FPS hes deptoyed police ofl«ers to supptt CDC c^abons augment secuniy operations smce 

deeihs and plague cases are increasmg SmKaiftoriay. 


Data Collactor Log 

VA Central Office 

IL 

14-May-03 

10:14 

IL SEOC reports that DuPage Ccurdy has MQun the prophylacbc distnbubon process. 


SEOC Event Log 

IL State EOC 

IL 

i4.Hay-03 

10:16 

Tc Lake County Government Employees from ftoynorflnnirl Cheinnan: Lake County |oned several other 
gevemmeiteciiOes In declark>g a disasier siiugflpR m partkvlaf jurisdciions. . as pari of the (toaster 
OecUiatiOo. littS Coieity Govemmers offices be closed begnning lomornw. Wednesday. May I4lh 
except for thoH^ersonnel requred lor the conbnualion of crtlieal government lunceons. This ism 
concurrence wMiUS OHS Secretary's advice Ihtf people lake a snow da^ ri order to remain isolated and 
sale In iheK hcrws.' 


Email 

Lake County EOC 

II 

U-Ua|b« 

10:30 

CCDPH notitiod of mealin^aeidwr this momng between Cook County Chief Oxmsel and IL Governor, 
considering this ^be ApBttfebloierronsl. suspended HtPAA and Blood Banl(S...aflow state to share 
communicable jltoaaf WBiniJUun with law enforcements: suspended licensing act so Oiel physksans can 
practice in placeMAHt they are not hcensed. ..temporarily suspend legal conslraints on other professionals 
so that others casApense medications, and cftsseminate at other places other than pharmaoes (tfislrawlion 
and administrabsfi of ant)biot)CS).., 


CCDPH Player Log 

Cook County DPH 

IL 

14-May^3 

10:30 

Press conference at IL JIC: confirms release o1 plague at United Center, Ohtore and Union Station - only at 
these Ifree sites. Governor actions: reguesis SNS deploymeni. Stale of Emergency In IL. deploymeni of 

WliCt team and IMERT Team lo increase security. 


EOC Log 

Lake County EOC 


T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reccrt$iA>eti&n 


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FO R OFRC I AL USE O N LV 


Pa^e 22 of 29 












FO R OFFIC I AL U SE ONLY 

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7/17/2007 922 AM 


Venue 

Date 

IfiDT) 

Time 

IFDT^ 

Description 

Analyst Comment 

Type al Bata 

Source 

Omanbetinn 

IL 

14May-03 

10:30 

Lake County £OC report to Lake County Healih Departmem Incident Command Posi: OuPage County 
be 9 )nnir}g prophylaxis of test responOers weh OuPage County Departmanl of Health stockple. 


Email ' 

Lake County EOC 

IL 

14'MayC3 

10:35 

lOHNO reggests Oeoxycyoine, C^rotoxadn, suigical masks, and vendlatom from VMI 


Dsia Colisclci' log 

•1DHNO 

WA 

14May-03 

11^)0 

FEMA Region X ROC iranafefrng management of recovery operaOons lo DFO tomorrow al 12:00 and wB 
nandle RDO-relateQ issues 


DaiaCtflKtorLog 

HHS Region X 
REOC 

IL 

14-May'03 

11:03 

IDPH Lab receives iLexecunve orders su^endlng privacy rights, elc... 


Oaia Coliecior Log 

IDPH lab 

(L 

14-May*Q3 

1IK)3 

FEMA Region V ROC reports to IL SCOC that 16 hospitals in Ctscago 6 subui&s an at n«simum capacily. 
FEMA needs to know the names o1 the hospHals io si^pon. Regardmg the NOMS leguesl • please report 
eiiormaiion to FEkitA liaison al IL SEOC for transirMtai back to FEMA Region V ROC 


SEOC Event Log 

IL State EOC 

IL 

14Mav03 

11:06 

Chioaco EOC confirmed O'Hare airport is closed, midivay aiipcrt ts dosed; Urvon staaon and al nHways are 
shut down: an bus systems in and om of ihe dry are suspended. 


Detailed in&dent Report 

DuPsge County 
EOC 

IL 

1A-May'03 

11:10 

IDPH has estabksheO an information holUne 1 *677 867 6332 


SEOC EverH Log 

IL Stale EOC 

WA 

14 May 03 

1120 

Based on new intormaiton, SeaTac « outside the TFR: ar iralfic conpoMrs can reroute trsfSc to avoid 
watvara 


Daia Collector Log 

FEMA Region X 
ROC 

11. 

14-MayH33 

11:25 

IL DOT kaison at O'Hare FedEx terminal reportad lo A SEOC that SNS has arrwad 


SEOC Even! Log 

IL Stale EOC 

IL 

14-Mey03 

11:30 

Chicago EOC rsceivad dahllcallon ol Chicago Transit Auihoniy sannce; service continues within dty MrM^ 
no service to suburbs or akporti > 


Deia Colleeior Log 

Chicago EOC 

WA 

14-Mav433 

1120 

NURT vnvM al VA Hotpui (WA) 


Daia ColUclorLog 

VA Hoeo<Ul (WA) 

IL 

14-May<03 

1122 

CCSEMA rsceivad fax from DHS/FEUA • A gramed Fedaral Emargency^SlaraMn 


Message & Event Log 

CCSEMA 

IL 

lAMay-OS 

11:33 

Vancouver officials scknowledged that Iheir ptigue viclims came from Air CMda flight t763 on May 10 fiom 
Chicago. 


Agency Log 

Cheego DPH 

IL 

14-Ma,.03 

1125 

CDC has amved at lOHNOtoessisiwiihfIfS. 


Data CoHecior Log 

lOHNO 

IL 

14 May-03 

11:40 

IL SEOC advised that the SWMDTs are afUiiBIng to rescue a security guard who has been shot behind 
buids^AZ at Nalco Cheirxcal 


SEOC Event Log 

IL Stale EOC 

IL 

14May-03 

11.45 

t 

CcK* CovntfCCC receives CDC Health Alert: (pcommends prophylans aftti protecflon of wofhers al 
sospecied relaasa sites. Three sites in1he Chicago area have been identified as Ikety exposure sies 

based on the ifiital epidemiologic informaikon. The sites idenefted are the United Center. Union Staikm and 
O'Hare Internatival Airport. Peisons who have been m these venues tor the period May 10 flmxigh May 13 
are advtsed to ssK an*)b■o^cb^ophylax6. 


HAN 

Cock County EOC 

IL 

I44ta^3 

11:45 

IDPH and COC l^sons at lOHNOf note that Feder^ SNS assets are being reto^ed w4houl a toderal 
disasTer dectara^'i' 


Data Coliecior Log 

lOHNO 

IL 

14-May^3 

11 >47 

SNS being loaded onto semis tor movemeni: scheduled tor actual move al 1220 CDT (1320 EDT) 


Command Post Log 

Naico Chemioai 
Plant Bldg 26 


T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reccnsirveti&n 


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FO R OFRC I AL USE O N LV 


Pa^e 23 of 29 













7/17/2007 922 AM 


.. Date Tima _ ^ , 

Venue Description 


Analyst Cominent 




IL 14>May 03 11:56 COC formally stgns over enOre SNS package. 


U. 1 S'MayOS 1 1 :56 IDPH UD f>eaps aixM shoovtg in al Naico Chemical PfvH. 


SNS ReceiMion Site 

Data Collactof at O'Hare 

\ Iniernaiional Airport 


IL 1AMay-03 12:00 


lr'9dB$ Hosp^iai receivect fev from lOPH: presumptive plague eitposure at Chtcago Union Station and OXart 
Airport InternaMrtal Terminal li m ite d to May (0, 


1 4-May-03 

12:03 

eiarffies plague cases and deaths in Chicago: 333 dead and 1 .676 suspecsed cases. Presidenaai 
declaration made. FBI confirms lerronsi aflack 

14.May.03 

12:15 

FEMA Region V ROC rsponed to IL SEOC: at 10:05 CDT {1 1:05 EOT), (be Presidem sigrwd an Emergency 
DeciaraBon tor IL : as of 10:55 COT (11:55 EOT). FEMA Region V ROC dd not have a copy ot deefaration 
nor assigned disaster number; not known if dectaralion apples to entire Slate or |ust speofic counties. 



IL 1 S'May'OS 12:30 Lake County EOC (eama that IL granted federal Emergency Declaration 



WA U'May-03 12:30 


IL 14-May03 12:3S 


King County update regarding Aiiports: Seatac e open and on r 
reduced to an elevation ol 2.000 ft. King Courtly Akpon open R 


DMORT has been activated • they wR deploy lo Hmes VA Hospital 
opened at Hmes VA 


y 

FA* t» 6ln clion»: TFB 
Akports opsn. 





DuPaga County EOC requested 
iL i4*MayC3 12:43 IL SEOC to Join a conference cal 
suggested that the county board ch. 


IDPH now has 30K * 30K doses avail 
IL l4'May'03 12:50 r>ot lo abuse system. Those who have bi 

coupons for identification. 300K doses to 




. City erf Chc^. IL JOC. and 
issirategy Hie 


be ciear about nek ^oups and 
{family members, etc) lo be ssued 


ase that Plague outbreak bnKed to Ikpe Chicago area locaborts from May 10: International 
Aiiport, United Center, and 


ledptied casiiaRy status from Seattle EOC: 20 Confirmed Dead: 130 Injured 


Data Cdleeior Log 

ARC • Chicago HQ 

SEOC Event log 

IL 8tal« EOC 


It. 

14May-03 

12:15 

Secunty guard has been rescued and transported to local hospital: inveehgaoons to conduci mterwew of 
guard. 

— 

^ 



f4 

> 

L 

Command Post Log 

Naieo Chemical 
Plant Bldg 30 

lA 

14.MeyK13 

I2:S6 

•4 

FEMA and TSA discuss obtaining waivers for emergency flights (brough reaincied airspqt^ 

n 


Dsia Coiioeior Log 

FEMA EST 



Coordlration SneKng 



Lake County EOC 


Dale Colleclor Log Chicago EOC 


Situalian Report 


Lake County EOC 


WA Slate EOC 




FPS has comadld COC in Atpnia to advise that Emergency Response Team b on stand-by and avarfable n 





13S8 

suDport their secflrity oueitS&IUhe event lhal there are proleste or aherhpts ID gel bud Iher lacilty lor plaQue 
amUoiM 4 

■ 


Dale Collector Log 

DOT CMC 


/A 

.> 

I' • . *A 

CCSEMA recsfvjipMEiMhKn Cook County Medcal Exarnner (CCMEj: leporl that Chicago Polce requested 




4 ' 

14-Ma)*IK.J3 10 



and received a dfCiayment of 6,000 National Guard troops who can assisl wilh mortuary saryioes. GOME'S 
office has leque^Kd 200 of these troops to be derficated to Cook County mortuary operations. 


Massage & Event Log 

CCSEMA 


T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reconsiruetion 








FO R OFFIC I AL U SE ONLY 

DRAFT 


7/17/2007 922 AM 


Venue 

Date 

rfiDTl 

Time 

rFDT^ 

Description 

Analyst Comment 

Tydd llOdta 

Source 

Omanijwttnn 

IL 

14May-03 

1325 

VNN report OHS Secretary ineiruaing all olizens wori^ al any o< tfie (or was at any o1 the) target sites 
should go immedlaiely to a medical faciivy lor medicaMns. DuPage County Emergency Manageiteni 

Agency response <$ to 1. Call hospitats. Z Law entorcement. 


Oala Cdiectcu lOQ 

DuPage County 
EOC 

IL 

14May-03 

1325 

DuPage County Commasioner recommends immediaie PIO relesase • 'Ignore* tie FEDS. Ksten to local 
oAcers. Conflict Oerween DHS Secretary's exact comments and whal had steady been released to Media. 


Daia Coltacior Log 

DuPage County 
EOC 

(L 

14-MayC3 

13:30 

SKS was received d 12 30 by Cook County Shertf $ odiee: contains only S% o< the shsenera we were 
suppose to rece^. 

- 

Agency Lss 

Cook County DPH 

n. 

14-May03 

13:30 

Request came ktio IL SEOC from EPA to perform mooaonno (BIOWATCH) at Unon Slaeon, O^lve 6eU and 
United Center EPA is moving some portable sampleig devices liom Wisconsin lo Oes Piames (lEPA’s 
Regional Office), Target lo have lha addilional sampbng localionsoperalionalia 1420 COT (1520 EDT) 


SEOC Event Log 

IL Stals EOC 

IL 

14«Mav03 

13:30 

VKN report GlOOO dams respons^Hity lor terronst attadi ol pMgue m Chicago. They say *lheir tenor is 
now our terror * 


SEOC Event Log 

IL State EOC 

IL 

14'M>y'03 

13*36 

Chicago DPH dosing maior assembries and events m Ctecago. 


CDPH 

Chicago DPH 

lA 

14-May'03 

13:98 

CcoA Courtly has reouesteO VA lo supply 25 refrigeraled bucks lo serve as morgue 


Dale CoHsmii' Log 

VACO 

IL 

14 May 03 

14:02 

Open conference cal between lOPH and the 5 ededed counties Issues discussed involved number of 
doses and ihe number ol cases which coutd be addressed Concern about uneifioeed people comng to 
dbOlDutton centers lo gel medicasons and geteng exposed at the site. Media problem • need lo get people 

10 understand Ihai rf they are not sympiomatic. were not at one oi the three siiea, and were not aiposad 
they donl need to lake medcabons Med*ca1>on$ are not an en^ess supply and llinoe may only be Vie lit 
state to be hk. 

Eadwr request for this necting suggested lop officials be 
praaenc. ihay doni appaar io Hfip attendad 

Data Ctf bdor Log 

Cook County EOC 

IL 

14Mav03 

14:24 

Presa raleasa: HHS Sands Medical SiaH To Chicago 


Email 

Lake County EOC 

IL 

UMay-03 

14:26 

Joint Made Release: HEALTH OFFICIALS ANNOUNCE LOCATIONS OF PLAGUE RELEASE Tf'C office of 
IL Governor announced ihia morning three locationa where plague was reiaasad by terronsls InLflilURiay. 
May to. The locationa are Union Slabon m downtown Chcago. 9ie International Terminal ot Otiare Mpod 
and United Canter on lha cH/s west side. No other sHes have been identified... Thoae who were^Lae^ 
the Plea on Saturday should receive ansbiouea 10 prevent the dqyelopnieni of Hness Thoae m close coDtU 
with someone axhibrimg symptoms should also reeaiva antib«iica. 


Email 

Lake County EOC 

IL 

14-May03 

14:40 

Cook Couny EOC rnon<: CCOPH personn*! stanog lo ottload ana biaak damn SMS: CCSEMA duty olftcei 
omita al 0'ldiiavitw oUcansing Ma. 


Email 

Lake County EOC 

IL 

13 May-03 

14:59 

Good Samaritan Hospital SR received call Ircm Loyola Hospital K> acffiffite Phase II o* il Fmefpency Medical 
Disaster Plan 


Data Collaeior Log 

Good Samaritan 
Hospilal 

IL 

14'May03 

15:00 

IL Department of Natural Resources (DNR) dosing IL stale parks 


SEOC Evani Log 

IL Stale EOC 

WA 

14-Mav-03 

ISflS 

USCO llftad No Sail Older In WA 


Agency Log 

KC EOC 

U, 

14.May-03 

15:20 

Chieago EOC recanred EmNel Smergeniy Message: Ihe SNS have been received, broken down and badad 
for delivery to Ihe dispanatng sue 


EmNet Emergency Message 

Chicego DPH 

IL 

14-May^3 

15:25 

Kane County would like wttt to release miairi^bh about SNS drsplbuton unU the momeig ot May 15 - only 

1 distribution sKe in Kane County: fear diat an ea'^'er release would not be beneTidal. Them appears lo be a 
consensus that information wili be reieaaed tNh evenrig staling thai dstnbubon sites w4l be made piMcon 
the morning of the 16 th, ' 


Oala Coilecior Log 

Kane County DPH 




information to IL SEOC: ° i liiHiiPT- "Qr“f DedaraMn applies lo 4 adected eourWes 
6ooi®l^iding Chicago) DuPage Kane gp0 Lake 


SEOC Event Log 

IL State EOC 



Bi 

Call from CcJBm SlafI & Duty Officer • SNS arrived al Bndgeview dispensing site 


Message & Event Log 

CCSEMA 

WA 

14^1^ 

16:02 



Situation Report 

KC EOC 

LL 

14Miy-03 

16:10 

Kane County hasAoived Its aBotrment of the SNS 


SEOC Event Log 

IL State EOC 

IL 

14-May-03 

T8;10 

Lake County EO^to lake Coirty HeaHh DepartmenI Incxient Command Peel concerning SNS ehEpbUty: 
Shortage of medteatons through SNS (IL Pharmaceutical Slookpie going lo hospdals): need 
recommendalFons as to how Hnted supply would be used. REPLY; Vendor Mariaged InventDry implemented 
• re^mbf^ of antibiotics w no longer an issue: however, mass prophyiaids • to any and aH - « being discussed 
by health depaimems m re^on. 


Email 

Lake County EOC 


T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reccrt$iA>eti&n 


DRAFT 

FO R OFRC I AL USE O N LV 


Pa^e 25 of 29 

















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7/17/2007 922 AM 


Venue 

Date 

rCDTl 

Time 

Description 

Analyst Comment 

TypMftOeta 

Source 

Omanizatinn 

IL 

UMai-02 

16:15 

Ciry ol CiHcago expecting SNS to arrive el 14:45 CDT { l S:45 EDT) 


Daia Collector Log 

Chicago FD Trammg 
Academy 

n. 

14-May03 

16:15 

ARC pt Greater Chicago CEO on VNN: ccnTirms blood supply n Chicago is sale - no need for new 

Oortations AJso. ARC o1 Greater Chicago Oisaslei Wettare Informahon System Ines are open tor aeparalnd 
fieTHly members. Red Cross heath and mental heaNh workers are al hosptals. airports, and ran stations to 
support stranded passengers 


Data CoHector Log 

ARC • Chicago HQ 

ll 

lA-MayOa 

1622 

Multiple hospdals eidlcale that there are no medical beds available. Concerns tegaidKig staffing. Hospnals 
have gone to lock down mode due lo increased crowds. 


DeiaMhoM Report 

DuPage County 
EOC 

IL 

14.May-03 

1625 

Chicago Fire Pepartmeni Chief: 120 boxes of inbcund SNS vrti slay at Fre Department, the reel wil go with 
City Depanrrtent of Health to distnbubon sfle. 


Daia Collector Log 

Chicago FD Training 
Academy 

WA 

u-Ma/'OS 

16i5 

WA Oept. of Agneutiure est^ished food control areas and road access checkpoints lor agricullural products 
m poiei^tiaHy affected counties lo prevent people consuming contamfr^aled fresh lood and milt products. 

Oont know 4 thfafe the fmal taxfGprrtrDl plan 

Talking points tor TOPOFF 2, Food 
and Safety Control 

WA Slate EOC 

WA 

m-May-OS 

16:32 

WA OOH realising exclusionary zone probably should have been expended 2 days ago. Concerned about 
wind increase and depersement of the elemencs WA OOH very concerned about Seattle's plan to lunher 
shrink the exclusion tone 


Dam CoHscio' Log 

WA Stall EOC 

11, 

14-M8y03 

16:35 

Oiicseo OEMC reounlM an adOltonal 4000 H NaUonal OuaRl trooDS 


SEOC EvenI Log 

IL Stall EOC 

IL 

ia-MayC3 

16:55 

IL offioals concerned lhai Preeideni«i Emergency Dedaratton vice Malor Disaster Oedenon results in loss of 
(a) cnsis counseling and lb) dwisler unempto)vnen| ato: Depsdmeni of Jue&ce may be able lo M gap wHh 
victKn fund. 


Dm Collaolor Log 

FEMA Region V 
ROC 

IL 

UMiy03 

16:56 

SNS amved ai Lake County drop.06 sue 


Dali ColiaclorLog 

Lake County EOC 

IL 

14.Mey03 

17:31 

Chieego EOC rtpons that SNS amved at The Lake County Reception Site at 14:50 CDtTTS SO EDT). Hhci [ 
been broken down end distnbubon lo krsi resporxiers has cemmefKed as of 16130 CDT (iTrO^EOT). 

Snuvrapiyt ruchad H. SEOC K 16:32 COT (17:32 EOT) 

Emn«l Emarganoy Umaags 

CNIcago DPN 

IL 

m-MayOS 

17-39 

Chtoago EOC deveiopirig a plan lor aH cay employees to receive irairsng and edueaiion on fte ofM und 
huards of the current outoretf^. Intormahon being developed by ah agenoee. with pie Chicago OFH Mking 
the lead. Informaiion wtH go out lo all agencies and PIOs Irom afleded groups. Loolung at a cooniBHffi 
program tor union and non*union employees. Devetopeig baexng video: coptos to al represerwed 
dspanments and agenoee, Trstneig video on Chvmei 23 - ihe AiolcfMl channel, press relsases akepdy 
on City s Inlemet site: this Iraining video will be on Use niemei dmltto Chicago OEMC PiOs puibng 
togelhar radio and TV Public Service Announcements •> 30 seconds. CNd|^ Aftemative Police Straiegies 
(CAPs) Ctsinbulion program - to eonleci block dubs: other languages to reach dMfse popubbons o( 

Chicego: Pobsn, Spanish. Arabic. English. Laadership by exampio • rnanagomeni wd lead mvon 
employees as they enter areas ccnsidefed to be ’at nsk.* 

- 

Dm Collaolo'Log 

Chicago EOC 

IL 

i4-May-03 

17:40 

CCSEMA received cell from Cook County Shentfs Command Center; MM responders have siai^^to receive 
the medicelion ai Bndgeview dtopensmg Pto 


Message & Event Log 

CCSEMA 

IL 

14-May-03 

17:40 

Cock CouMy EOC PrKS Ralsask. ffiRWKCtlATE RELEASE . GOVERNORAUKOUNCES RECEIPT. 
BREAKDOWN AND DISTRIBUTION QF SKS 


Press Release 

Cook County EOC 

WA 

lA-May-OS 

17:51 

WA DOH )usi receives fax with raOiotogiCdl data ir^ arrived at $£OC yesterday. Ctoar that the readings 
exceed boundary of Cit/s exckisranary ar^ 


Daia Coileclor Log 

WA SIM EOC 

IL 

l4*May-a3 

18:00 

CFD Fire Academy Commander reports to Clftago EOC: they have noMtod outside agenctos to begm 
picking up SNS prophylactic mods el Fire Aceiftny: Chicago Pobce Dept.'s picked 5500 doees: Chicago 
JlFH wiH rslaase rest as necessary. ^ 


Daia Collector Log 

Chicago EOC 

IL 

14-May-03 

18.15 

Lake County ttC. IL Governor recommends public and employees of non-essenesl businesses to stay 
home until furtfw nodce: Chtoago area - target of lerrorisl attack. 


Agency Log 

Lake County EOC 

IL 

1«Hey-03 

1822 

Chicago EOC: $SS arrivvu. IMdng on u ^ugs und 08:00 tomorrow morning as was dectoed wfh the other 
counties. 


Data Colleetor Log 

Chicago EOC 

iL. 

14-May 03 

18 42 

IL SEOC bnefinge^Mcago drstnbubon centers mil operate 8:00anv4i30pm tomorrow / Cook and Lake 

Counties will opdfral BiOOam - closrig bme not toimn: DuPage & Kane Counbee - no eitormabon 


SEOC Event Log 

IL State EOC 


T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reccnsirveti&n 


DRAFT 

FO R OFRC I AL USE O N LV 


Pa^e 2e of 29 















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7/17/2007 922AM 


Venu& 

Date 

Tima 

IFDT^ 

Description 

Analyst Comment 

TyRMABata 

Source 

Omanb.atir>n 

IL 

14Mdy-03 

18:30 

SMS Reception Site reported to the IL JOC that the SN$ relay had been delivered and the detail secured 

The Commend Post at O'Hare has been sealed end closed. The relay was compleied without «icident 


SEOC Ever^i log 

IL State EOC 

lA 

i4-May-03 

18:50 

Defense CoordlnaUng Offteers d^loyed lo SeelUe end Chrcepo 

Tbs was reported between 1630 and 19:20 EDT 

Dale Collector log 

VA Central Office 

JL 

14-Ma703 

19^)3 

Chieego DPH receded EmNet emergency message. DuPage County has begun prophylacUc distribulion 
procedures 


EmNet &myeitcy Message 

Cbicago DPH 

WA 

i4.May03 

20:00 

WA SCOC rspons m SlTRSP that WA NalioiW Guard wH acttvate 2 addtional task twees (a total of 500 
soldiers) to support law eotorcemem agencies. 


Siluaiiori Repon 

WA State EOC 

(L 

14May-03 

20:26 

IL SEOC received EmNei emergeiKy message* Cook County Dispensing she located m Bridgeview has 
closed as ol 19.00 CDT (20:00 EDT). The first responders have been given the medcalions. The 
expensing site will reopen at 06:00 CDT (OdtK) EOT) ori May 15 lor dspeneng to lha pubke 


SEOC Event log 

IL State EOC 

fL 

14M9y-03 

20:37 

IL SEOC provided the tollowing miect: Vendor Irfanaged Itweniory from the SNS airwed ei IL. The Slate oi 

IL hes begun disiribution of aniipioiics end medicei supplies. SNS requests made by local heenh 
deptanments ar>d hospitals win conttnu# lo be fined lor ihe lertgih of the event 


SE(X EveiHLoj 

IL Stale EOC 

IL 

lA-Mev'OS 

20:38 

IL SEOC repon: VMi has arrived at OHare State dtsinbuiion staff are bceeiung down and wM disirtiute lo 
local |urisdictior%s as previously rtponed 

. 

SEOC Eveni Log 

IL stale EOC 

II. 

14 Mfiv 03 

21:30 

SNS DIsnieutian Process: CtHcago sipeclsa 60.000 Qosss. SNS eroksn down al CFA (CMigo free 

AceOsmy)' only S.500 sent over. 


Oala Colleetor log 

Chicago EOC 

IL 

14-M97'03 

22:22 

IL SEOC racetvH repon from IL Siaie PoHce Unified Command Post advised of suspeci m custody who 
provided icdowirtg inlo: (1) Member of Free America Group: (2) No hosiages in building: (3; There a lab 
equipment in men's room ol Nalco Chemcal 6idg 32: (4) A ral car on west side of 6ldg 32 hsmniprvcs: 

(5) A tank m Bldg. 32 on north side has axplosives: (6) A ffactor/lrailer parksd oulside Bldg. 32 wMi^toewn 
chemicals: (7) There are several booby traps m Bldg. 32 


SEOC Event log 

IL Stale EOC 

IL 

14May03 

23:15 

IL SEOC sent las 10 S eouMies and CMesgo Dial VMI has essn Bong bmiandoiini al OXara' 

aiipon. Available upon reoMsi 10 eacn county and CNcago. 


SEOC Event log 

11 State EOC 

IL 

14'Mgy03 

23:36 

Tacncal Rasponse Team (TRT) made entry into Nalco Chemteal bu4|Efi *32 and are mside 


Command Post log 

Nalco Chemical 
Plant Bldg 146 

IL 

14-Mt7-03 

23:45 

TRT advised 3 males and 1 female it> custody 


Command PosI Log 

NALCO chem plant 

bldg 9 

IL 

iS-May-OS 

ow 

Repon to IL SEOC: TRT entered Nalco Chemical Buriomg. 3 male. i fematom custody. 4 subfects wtf 16 

TRT belr>g contaminated. Preparmgto sweep for explosives. lnvs$bgat*r>g0ersonr>el wadng lo irfisrrogate. 


SEOC Evan) Log 

IL Stale EOC 

lA 

1S-May.a3 

0:1S 

C6P Update: 

•Holding all containers Irom high nsk deitntnee 'PWend. Oiangeland. and Itodfend) vansHng through CSI 
perecipeeng countries and increase evonanon semnny up to 100% of wmtainers desiined fw the U$ 
•Deployed Border Patrol Tactical Unit IBttTAC) uqRi il2 merabesaaMh) to SeatSe and to a sta^png 
location near Chicago; CBP wil coordinate wuh ite US Marshal %tomce for J-PATS flights to provide air 
Transportation Security Admirasitalion 

•Passenger Manifssis for all mtemationai flints departing OHarn smee t * l^y shared wdi State and 

Foreign LE counterparts to locate poienital ptRgue cases 


Secretary's Morning Summary 
Operational Response 

OHS HSCantar 

lA 

i5'Mav-a3 

. 

0.15 

•Nai«riwide:^berty Shield level i and 2 transf^Rabon restncborts. 

•Netnnwide. Algassenger rail slopped. TSA authorty questioned by Pederaf RaIrDad Admimslration 
-Port of Chicagvat WarSec 3 • commercia] vessel crews restricted to vessels 
•Chicago: Secof^ day of Iranfportatron restridme in Metro area 


Sacralary's Morning Summary 
Operational Response 

DHS HSCenter 

lA 

1&-MQ^3 

0:15 

EP&R Update: 

•EP6RE:iperts on scene in Chicago: t3NDMS speoaHsis. 14 EPI irteligence service offleers. CCRP: 150 
Nurses, 25 Physicians (amve ISfrfay), transporl of 175 Medical Peisomel to ChK:ago 
• EPS R Assets msedto^DMATS. t OMORT, 50 respiratory Technicians 


Secretary's Morning Summary 
Operational Response 

DHS HSCer>ter 

n. 

1 5*May-Q3 

■020 

IL State Pohee; t male subiect with sucking cbest would being transporied to Chiisi Hoepflal. Oak lawn. 2 
investigators in ambularvce. uniformed officer also being sent to hosprt^ for security. Other 3 subfects 
uninsured, being transported to Bedford Park PD. FBI en roue. No iniuries to ISP. Cherwcal stR unknown. 
Decon by Bedford Park Fire departmenL 


SEOC Event Log 

IL Slate EOC 


T2 /lAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reconsin>cii<>n 


DRAFT 

FO R OFFIC I AL USE O N LV 


Page 27 of 29 













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7/17/2007 922 AM 


Venue 

Date 

ifOT\ 

Time 

rFDT^ 

Description 

Aftalysl Comment 

TyiMWata 

Source 

Omanbatiim 

IL 

iSMay-03 

035 

fL Slate Police meeting with FBI. They are n agreemeni with bnn^ng ri team litim US ERA 


SEOC Event Log 

IL State EOC 

(L 

i5-May-03 

133 

Chicago Poice Dept, begins disihbutton ot prophylaxis to PoGee department 


Daiii CoHactor Log 

Chicago EOC 

IL 

IS-MayOa 

1:41 

IL SEOC update on Nako Chemcal BuilAng: ISP repons Bomb Squad has located two exploswe devices. 
Device 9^ ts attached to rad tank car containing hyt^azine and is a bnetcaae. Device 92 is attactied to a rail 
tanA car containing dictdorobuMne and is equipped wkh a motion sensor. Wortung with Chicago Fre/Pdce. 
Bedford Park Fire>' Pokes . lEMA & IMERT to exlend evacuation wea to 1 /2 mite 


SEfac&Mlog 

IL Stala EOC 

lA 

i5-Ma»-03 

5:45 

FEMA EST Siruation Update. To ImH the poieniial tor spreading ihe deease, the transpodabon centers ol 
O’Hare Airport. Midway Airport, Union Station and (he Pod ct Chicago have been ctosed 


RegKm % ROC HputkC EP&R 

situation repsn 

OHS/HSCentar 

lA 

15May03 

730 

FEMA EST Situatton Updele DKS reports Iransoortatton restnetions m SealBe have been Itted. except the 
nuclear power ptant. 


Data Colteelor log 

FEMA EST 

U. 

1S-May'03 

9:30 

Jomt media release: Oepensing Sea Locations tor Amtoiotics Announced. Heaiih Oepts wil provide 
antibiotics lor ak (hose alfected by plague outbreak. Cleiies: Clscago. 100 W. Ve^rwa Street: Coca Courdy. 

1 20 St. James Place, BckngbrooA, DuPage Ccunfy: 34 trlarwi Gardens. Wheelon. Kan# County: 46 Para 
Place, Aurora, lake County 75 Boardwalr. Wsueonda 


Joint Media Release 

CookCoumy EOC 

lA 

1SMav-03 

9:57 

VNN reporl: 103 Deaths m Canada • 94 Vancotnrer. 21 Toronto. 22 Ollawe. i E^nonion. 2 cases Montreal 6 
Winnlp^ 


Situation report FEMA NEOC EST 

DMS CAT 

lA 

15MBy03 

937 

FEMA EST Situation Update' FT A is wohung with WA DOH lo have Femes and lermmsls at Seattle. 
Bremerton, end BainOndge decornammated. 


Situalton r«pon FEMANEOC-ESt 

OHS-CAT 

IL 

l5-May-03 

930 

Chiesgo ECO announced prophylaxis eilee open to the pubUe 


Data Coflacio' log 

Chicago EOC 

IL 

IS-htay-OS 

930 

VNN nms noiHying (nt puUc Of Mpandng of mMs: SympumMc Mnox are 10 weh jnont.^n 

Persona who were al ihe 3 aKea or ihoae peraona exposM to people who were al fha^S^lDa ara lo go (o ^ 
facility 10 gel meos. ‘ 


Data Colleeiorlog 

Cook Counry EOC 

lA 

1S-May-03 

9:57 

VNN reporl: Bio lab found In Badtord. IL 


Oaia CollaclorLog 

DOT CMC 

IL 

1SMey03 

1033 

Kane County OPK rapons SNS arnvee and brought down lor disiribuaon 


DalA Coileeior log 

IMSA Kar>e OPH 

IL 

15-May03 

1033 

IL SEOC reports: lake County began dlepensing operaltone at COT (9 32 EDT) 


SEOC Event log 

IL Stale EOC 

IL 

1&-May«03 

10:06 

IL SEOC reporte: Du Pagt County began d^pensing SNS at 09 00 COT (093^ EOT| 


SEOC Event log 

Il State EOC 

IL 

ISMey-Od 

1020 

ISP and FBI conUrm backpacks wKh earceci cans ware loceied at Arpon end were uaeo ty dtetnbuttog of 
Ptoguk 


SEOC Event log 

Il State EOC 

IL 

I^MayOd 

10:32 

IL SEOC received EmNel Emergency meseaga from IL JOC: FEMA rtioeiinniMb ti indicated iha» there has 
been a toll Iree t selHip tor ananoal assdianee and tor hearing mpatred Alee rwmbureemeni it a* akable to 
local and state agendas tor eiigibie costs of equipment, contracts and paivmel overtime retotod to 
emergency services in dealing with ptogve event 


SEOC Evani Log 

IL Stele EOC 

il 

13-MIIV-03 

10:39 

FBI reports lhai they have mtormation (hat suipects dispersed eerosoksed ptogue tom backpacks • it * not 
known at this Qme if ihey were disperied at additionai sites or same as ongvial attack • stale pobca ^reeled 
to get decon ot possibto addrtional reto^ies. 


Dala Collaclorlog 

IL Stala EOC 

IL 

15-MaH3 

10:40 

IL SEOC is requesimg me DMORT assidUhe me(t>cal e^a'^fnem otflee of Cook County 


SEOC Event log 

IL State EOC 

IL 

15-MBV-03 

10:59 

IL SEOC reports aU SNS diembulion sdes W'Ued op«n and operedpnai 


SEOC Event log 

IL State EOC 

lA 

13-May-03 

11:06 

The Governor of Wisconsin eem a requesl tolEMA Rejpon V wh«h was passed to OHS EP&R tor a dtsaster 
declaration: The Governor’s request dated 15.2003 sahshee Ihe venous statutory and regulatory 

roQiaanacils of Public Law 93*288. as amend^TheJkivemot has requested a maior disaster declaration 
tor the courses o( Ker>o$ha. Milwaukee. ar>d a resuh ol an outbreak of Pneumonc Plague, the 

Governor SQi^lmented the State Emergency Pltot*on May 1S200Q and declared a slate emergency tor these 

wunites on 1^19. 2003. 


Data Coilecior Log 

DOT CMC 

IL 

1&*Mav03 

12.30 

Report from CtGago EOC that plague is sUI present at Union station. United Center. OXare 


Data Coltector Log 

Chicago JOC 

IL 

1S>Mev-03 

14:00 

From IDPH to 0^. of Stale Masion; VNN report slated lOPH did not want assdtaice fnMn other naltons due 
to lesser quality 9 health ctre 6 language barner lOPH viewed this as arrogance and requested to know 
who made iNs stotement 


AgoncyLog 

DOS Liaison at 
(OPH 

IL. 

l5-May-03 

14 20 

/ 

FBI announces kBSbd Center, Uniori Staboo. and Terminal 3 at OXare cleared as crime scenes. US EPA 
says they can bb opened lo the pubke. 


SEOC Event Log 

IL State EOC 


T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reccnsirveti&n 


DRAFT 

FO R OFRC I AL USE O N LV 


Pa^e of 29 

















IL SCOC received request from FBI HMRU unri. Request asKs tor Z Haztrfal officers from 50i CST to assist 
in operations. CST soWiers are available At^utant General has been notified and appiwed the irisscn 
request, with one eOpulalion • if CST gets tahed by Staie^Feds as a team. Z solders wil return lo CST control 
for mission S4^port. 

IL SEOC received EmNet Emergency Message from IL JOC: FEUA Region V ROC has imScated that the 
Mabonal Homeland Security AcMsoiy Sysiem level ml be lowered from Red to Orange with the EXCEPTION 
of Chicago and New York City, which shaH remain at Red. 


Chicago Oepartmern of Health a Human Services notifies CNcago OEM of reducted aien solus from 'Red* 
to ‘Orange' r^anonwide except Chicago and New York City. 



15-May03 20:40 


Chieago EOC receives formal notificalion that Nationwide Threat level lowered from Red to Orange except 
tor New York City and Chicago 


JOC received Update from Chicago Fire Department regardmg crash at Midway Airport* helcopler was 
completely destroyed, 10 dead, SI senous mjunas. S9 minor ar>d 79 mmimal. CPO says that oasfr was an 
aceiderH and not terronsl attack {corresponds to MSEL 9 308S|. 


As of 19:30. biological testing results are as tolows per the Chicago HMRT artd EPA: CfH^ • neg. tor 
y9fsinla Rwos ; Union Station • neg. for yersna Pesfrs . United Center • Posove for Y^n/nm Rasas 



T2 AAR Annex A - T2 MASTER RECONSTRUCTION 
T2 Reconstruction 






7/17/2007 922 AM 




ABS 

AMS 

ARAC 

ASPA 

ATF 

BC 

BDC 

BICE 

BOLO 

BOMA 

Ca DTPA 

CAT 

CBP 

CCC 

CCDPH 

CCSEMA 

CDC 

CDRG 

Ce 

CEPPO 

CFD 

CMC 

CMRT 

COOP 

CPD 

CST 

CTA 

DC 

DEST 

DHS 

DMAT 

DMAT 

DMORT 

DOH 

DOJ 

DOS 

DOT 

DPH 

DPMU 

DTPA 

EDP 

EIS 

EMD 

EMNET 

EMSHG 

EOC 

EPA 



Integrated Acronym List 

Arson Bomb Squad 
Aerial Measuring System 
Atmospheric Release Advisory Capability 
Assistant Secretary, Public Affairs 
[Bureau of] Alcohol, Tobacco, and Firearms 
British Columbia [CAN] 

Bomb Data Center 

Bureau of Immigration and Customs Enforcement 
Be On Look Out 

Building Owner and Managers Association 
[trisodium] Calcium Diethylenetriamine Pentaacetic Acid 
Crisis Action Team 
Customs and Border Patrol 
Crisis Coordination Center 
Cook County Department of Public Health 
Cook County Sherrifs Emergency Management Agei^^ 
Centers for Disease Control [and Prevention) 

Catastrophic Disaster Response Group 
Cesium 

Chemical Emergency Preparedness a ndrEre venion Offic’ 
Chicago Fire Department 
Crisis Management Center 
Consequence Management Response 
Continuity of Operations ^Lins 
Chicago Police Departmen 
Civil Support Team 
Chicago Transit Authority 
District of Columbia 
Domestic Emergency Support Team 
Department of Homeland Security 
Disaster Medical Assistance Team 
Disaster Medical Assistance Team 
Disaster MORtuary Team 
Department of Health 
Department of Justice 
Department of State 
Department of Transportation 
Department of Public Health 
Disaster Portable Morgue Unit 
Diethylenetriamine Pentaacetic Acid 
Emergency Disaster Plan 
Epidemic Intelligence Service 
Emergency Management Division 
Emergency Network 

Emergency Management Strategic Health Care Group 
Emergency Operations Center 
Environmental Protection Agency 






ERT Evidence Response Team 

ESF Emergency Support Function 

ESF-10 ESF Hazardous Materiel 

ESF-8 Emergency Support Function 8 (Health and Medical Services) 

ESF-9 Emergency Support Function 9 (Urban Search and Rescue) 

EST Emergency Support Team 

EST Emergency Support Team 

FAA Federal Aviation Administration 

FBI Federal Bureau of Investigation 

FCO Federal Coordinating Officer 

FDA Food and Drug Administration 

FEMA Federal Emergency Management Agency 

FHWA Federal HighWay Administration 

FPS Federal Protective Service 

FRA Federal Railroad Administration 

FRMAC Federal Radiological Management Center 

FTA Fedearl Transit Administration 

GLODO Group for the Liberation of Orangeland and the Dlteint^on 
Gm Gram 

GSA General Services Administration 

HAN Health Alert Network 

HAZMAT Hazardous Materials 

HHS Health and Human Services == 

HIPAA Health Insurance Portability and Accountability Act 
HMRT Hazardous Materials Response Team 

HMRU Hazardous Materials Response Unit 

HMRU Hazardous Materials Response Unit 

HMRU Hazardous Materials Response Unit 

HQ Headquarters 

HRT Hostage Rescue Team 

HSAS Homeland Security Advisory System 

HSAS Homeland Security Alert Status 

HVAC High Volume Air Conditioning 

IC Incident Command(er) 

ICE Immigration and Customs Enforcement 

ICP Incident Command Post 

ICS Incident Command System 

IDPH . Illinois Department of F*ublic Health 

lEMA Illinois Emergency Management Agency 

IL SEOC Illinois State Emergency Operations Center 
IMERT Illinois Medical Emergency Team 

IMSURT International Medical SURgical Response Team 
lOF Interim Operating Facility 

lOHNO Illinois Operational Headquarters and Notification Office 

ISP Illinois State Police 

JIC Joint Information Center 

JOC Joint Operations Center 

JTF Joint Task Force 






LQRAM 

MARSEC 

MCC 

MCI 

MERRT 

METRA 

MRV 

MSEC 

MST 

NAWAS 

NCEH 

NCID 

NDMS 

NJTTF 

NMRT 

NMRT 

NNSA 

NPP 

NPS 

NRC 

NRT 

OEM 

OEMC 

ONCRC 

OSC 

OSHA 

OSLGC 

PAT 

PCR 

PFO 

PHSKC 

PIO 

PPE 

Pu 

RAP 

RAP[T] 

ROD 

ROD 

REAC 

REOC 

RHA 

ROC 

RSAN 

RTA 

S-60 

SABT 

SAC 

see 



Large Quantity RadioActive Material 
Maritime Security 
Master Control Cell 
Mass Casualty Incident 

Medical Emergency Radiological Response Team (Veterans Affairs) 

Metropolitan Rail Agency 

Mobile Response Vehicle 

Master Scenario Event List 

Management Support Team 

NAtional WAming System 

National Center for Environmental Hazards 

National Center for Infectious Diseases ^ 

National Disaster Medical System 
National Joint Terrorism Task Force 
National Medical Response Team 
National Medical Response Team 
National Nuclear Security Administration 
Nuclear Power Plant 
National Pharmaceutical Stockpile 
Nuclear Regulatory Commission 
National Response Team 
Office of Emergency Management 
Office of Emergency Managemen't^feom munlcati ons 
Office of National Capitol Region C^rdn^ffin*^ 

On-Scene Coordinator •. 

Occupational Safety and Healfl ifAdm inistraTion 
Office of State and Local Government Coordination (DHS) 
Preliminary Assessment Team 
Polymerase Chain Reaction 
Principle Federal Official 
Public Health-Seatile & King County 
Public Information Officer 
Personal Protective Equipment 
Plutonium 

Radiological Assistance Program 
Radiological Assistance Program [Team] 

Radiolotgical Dispersion Device 
Radiological Dispersal Device 
Radiological Emergency Assistance Center 
Regional Emergency Operations Center 
Regional Health Administrator 
Regional Operations Center 
Roam Secure Alert Network 
Regional Transportation Authority 
DOT Office of Intelligence and Security 
Special Agent Bomb Technician 
Special Agent in Charge 
Secretary's Command Center 





SEATAC Seattle-Tacoma [Airport] 

SEOC State Emergency Operations Center 

SERT [HHS] Secretary's Emergency Response Team 

SFD Seattle Fire Department 

SHE State Health Liaison 

SIOC Strategic Information Operations Center 

SME Subject Matter Experts 

SNS Strategic National Stockpile 

SODO South Of DOwntown [Seattle] 

SPD Seattle Police Department 

SPU Seattle Public Utilities 

STB Surface Transportation Board 

SWAT Special Weapons And Tactics 

SWMDT State Weapons of Mass Destruction Team 

TFR Temporary Flight Restriction 

TOPS TOPOFF Pulmonary Syndrome 

TRT Tactical Response Team 

TSA Transportation Security Administration 

UC Unified Command 

UCS Unified Command System 

US&R Urban Search and Rescue 

USAR Urban Search and Rescue 

USMS United States Marshal Service 

USSS United States Secret Service 

VACO Veterens Affairs Central Office 

VCC Venue Control Cell 

VMI Vendor Managed Inventory 

VNN Virtual News Network 

WA Washington [State! 

WH White House 

WMD Weapons of Mas’s J>estrucSon 

Zn DTPA [trisodium] Zinc Diethylenetriamine Pentaacetic Acid 









V 




Washington Acyonyms 

ABS 

Arson Bomb Squad 

DEST 

Domestic Emergency Support Team 

DMAT 

Disaster Medical Assistance Team 

DOH 

Department of Health 

EMD 

Emergency Management Division 

EOC 

Emergency Operations Center 

ERT 

Evidence Response Team 

ESF 

Emergency Support Function 

EST 

Emergency Support Team 

FEMA 

Federal Emergency Management Agency 

HAZMAT 

Hazardous Materials 

HMRT 

Hazardous Materials Response Team 

HMRU 

Hazardous Materials Response Unit 

IC 

Incident Command(er) 

ICS 

Incident Command System 

lOF 

Interim Operating Facility 

JOC 

Joint Operations Center 

MARSEC 

Marine Security 

MCI 

Mass Casualty Incident 

MSEL 

Master Scenario Event List _ 

NJTTF 

National Joint Terrorism Task Force 

NMRT 

National Medical Response Team 

PHSKC 

Public Health-Seattle & King County^^L 

PIO 

Public Information Officer .. ^ 

RAP 

Radiological Assistance ftogram 

RDD 

Radioloigical Dispersion Device 

ROC 

Regional Operations Center 

SABT 

Special Agent Bomb Technician 

SEOC 

State Emergency Operations Center 

SEOC 

Seattle Emergency Operations Center 

SFD 

Seattle Fire Department 

SHL 

State Health Liaison 

SIOC 

Strategic Information Operations Center 

SODO 

South of Downtown 

SPD 

Seattle Police Department 

SPU 

Seattle F^iblic Utilities 

TFR ^ 

Temporary Flight Restriction 

ISA 

Transportation Security Administration 

UC 

Unified Command 

UCS 

Unified Command System 

USAR 

Urban Search and Rescue 

VCC 

Venue Control Cell 

VNN 

Virtual News Network 



Interagency Acronyms 

ASPA Assistant Secretary, Public Affairs 
AMS Aerial Measuring System 

ARAC Atmospheric Release Advisory Capability 

ATF [Bureau ofj Alcohol, Tobacco, and Firearms 

BC British Columbia [CAN] 

BDC Bomb Data Center 

BICE Bureau of Immigration and Customs Enforcement 

BOLO Be On Look Out 

Ca DTPA [trisodium] Calcium Diethylenetriamine Pentaacetic Acid 
CAT Crisis Action Team 

CBP Customs and Border Patrol 

CCC Crisis Coordination Center 

CDC Centers for Disease Control [and Prevention] 

CDRG Catastrophic Disaster Response Group 
Ce Cesium 

CEPPO Chemical Emergency Preparedness and Prevenion Office 
CMC Crisis Management Center 

CMRT Consequence Management Response Team 
COOP Continuity of Operations Plans 

DC District of Columbia 

DEST Domestic Emergency Support Team 

DHS Department of Homeland Security 

DMAT Disaster Medical Assistance Team 

DMORT Disaster MORtuary Team 

DOJ Department of Justice 

DOS Department of State 

DOT Department of Transportation 

DPMU Disaster Portable Morgue Unit 

DTPA Diethylenetriamine Pentaacetic Acid 

EMSHG Emergency Management Strategic Health Care Group 

EOC Emergency Operations Center 

EPA Environmental Protection Agency 

ERT Emergency Reponse Team 

ERT Evidence Response Team 

ESF Emergency Support Function 

ESF* 1 0 ESF Hazardous Materiel 

ESF-8 Emergency Support Function 8 (Health and Medical Services) 

ESF-9 Emergency Support Function 9 (Urban Search and Rescue) 

EST Emergency Support Team 

FAA Federal Aviation Administration 

FBI Federal Bureau of Investigation 

FCO Federal Coordinating Officer 

FDA Food and Drug Administration 

FEMA Federal Emergency Management Agency 

FHWA Federal Highway Administration 

FPS Federal Protective Service 

FRA Federal Railroad Administration 

FRMAC Federal Radiological Management Center 


5 ^ 








FTA Fedearl Transit Administration 

GLODO Group for the Liberation of Orangeland and the Destruction of Others 
GSA General Services Administration 

HAN Health Alert Network 

HHS Health and Human Services 

HMRU Hazardous Materials Response Unit 

HQ Headquarters 

HRT Hostage Rescue Team 

HSAS Homeland Security Advisory System 

ICE Immigration and Customs Enforcement 

IMSURT International Medical SURgical Response Team 
JIC Joint Information Center 

JOC Joint Operations Center 

JTF Joint Task Force 
LQRAM Large Quantity RadioActive Material 

MARSEC Maritime Security 
MCC Master Control Cell 
MCCUE Master Control Cell Un-Eva!uator 
MERRT Medical Emergency Radiological Response Team 
MRV Mobile Response Vehicle 

MST Management Support Team 

NAWAS NAtional WAming System 
NCEH National Center for Environmental 
NCID National Center for Infectious 
NCID National Center for Infectious Diseases 
NDMS National Disaster Medical System 

NMRT National Medical Response Team 

NNSA National Nuclear Security Administration 

NPP Nuclear Power Plant 

NRC Nuclear Regulatory Commission 

NRT National Response Team 

ONCRC Office of National Capitol Region Coordination 
OSC On-Scene Coordinator 

OSHA Occupational Safety and Health Administration 
OSLGC Office of State and Local Government Coordination (DHS) 

PAT Preliminary Assessment Team 

PFO Principle Federal Official 

PPE Personal Protective Equipment 

Pu Plutonium 

RAP[T] Radiological Assistance Program [Team] 

RDD Radiological Dispersal Device 

REAC Radiological Emergency Assistance Center 
REOC Regional Emergency Operations Center 

RHA Regional Health Administrator 

ROC Regional Operations Center 

RSAN Roam Secure Alert Network 

S-60 DOT Office of Intelligence and Security 

SAC Special Agent in Charge 

see Secretary's Command Center 




SEATAC Seattle-Tacoma [Airport] 

SERT [HHS] Secretary's Emergency Response Team 

SIOC Strategic Information Operations Center 

SME Subject Matter Experts 

SNS Strategic National Stockpile 

SODO South Of DOwntown [Seattle] 

STB Surface Transportation Board 

SWAT Special Weapons And Tactics 

TFR Temporary Flight Restriction 


TSA Transportation Security Administration 

US&R Urban Search and Rescue 

USMS United States Marshal Service 

USSS United States Secret Service 

VACO Veterens Affairs Central Office 
VCC Venue Control Cell 

VNN Virtual News Network 

WA Washington [State] 

WH White House 

WMD Weapons of Mass Destruction 

Zn DTPA [trisodium] Zinc Diethylenetriamine Pentaacetic Acl 




% 













Illinois Acronyms 

BOMA Building Owner and Managers Association 

CCDPH Cook County Department of Public Health 

CCSEMA Cook County Sherrif s Emergency Management Agency 

CFD Chicago Fire Department 

CPD Chicago Police Department 

CST Civil Support Team 

CTA Chicago Transit Authority 

DHS Department of Homeland Security 

DMAT Disaster Medical Assistance Team 

DPH Department of Public Health 

EDP Emergency Disaster Plan 

EIS Epidemic Intelligence Service 

EMNET Emergency Network \ 

EPA Environmental Protection Agency \ 

GLODO Group for the Liberation of Orangelandia and the Destructioi?^O^h|0 ^ 
Gm Gram ^ ^ 

HAN Health Alert Network * ^ 

HazMat Hazardous Materials 

HIPAA Health Insurance Portability and Accountability Act 

HMRT Hazardous Materials Response Team 

HMRU Hazardous Materials Response Unit \ 

HSAS Homeland Security Alert Status 

HVAC High Volume Air Conditioning 

ICP Incident Command Post 

IDPH Illinois Department of Public Health 

lEMA Illinois Emergency Management Agency 

IL SEOC Illinois State Emergency Operations Center 

IMERT Illinois Medical Emergency Team 

lOHNO Illinois Oper^on al He adquarters and Notification Office 

ISP Illinois State Police 

JOC Joint Operations Center 

METRA |Metropolitan Rail Agency 

NDMS National Disaster Medical System 

NPS National Pharmaceutical Stockpile 

OEM ■ Office of Emergency Management 

OEM Office of Emergency Management 

OEMC Office of Emergency Management Communications 

PCR JPolymerase Chain Reaction 

PIO Public Information Officer 

PPE Personal Protective Equipment 

RTA Regional Transportation Authority 

SNS Strategic National Stockpile 

SWMDT State Weapons of Mass Destruction Team 

TOPS TOPOFF Pulmonary Syndrome 

TRT Tactical Response Team 

VMI Vendor Managed Inventory 

VNN Virtual News Network 



T2AAR 


T2 


TOP OFFICIALS (TOPOFF) 
EXERCISE SERIES: 


TOPOFF 2 (T2) 


After Action Report V 


ANNEX B 


V.C\ 



September 30, 2003 


Information contained in this document is intended for the exclusive use of T2 Exercise Series 
participants. Material may not be reproduced, copied, or furnished to non-exercise personnel 
without written approval from the Exercise Directors. 




T2AAR 


T2 




T2AAR 


T2 


TOP OFFICIALS (TOPOFF) 
EXERCISE SERIES: 



TOPOFF 2 (T2) 


After Action Report V 


ANNEX C 


September 30, 2003 


Information contained in this document is intended for the exclusive use of T2 Exercise Series 
participants. Material may not be reproduced, copied, or furnished to non-exercise personnel 
without written approval from the Exercise Directors. 





T2AAR 


T2 





II ' ' nil 1 

r ^ 



v\ 


• 1 


DRAFT 

Ollics lor Oomotic PropiroOnm 


NATIONAL CAPITAL REGION 
FUNCTIONAL EXERCISE 



after-a^Tion 

MAY 12/2003 




This project was supported by the U.S. Department of Homeland Security (USDHS) Office for 
Domestic Preparedness (ODP). Points of view presented in this document are those of the 
authors and do not necessarily represent the official position of ODP. 




National Capital Region Functional Exercise 
DRAFT After-Action Report DRAFT 


TABLE OF CONTENTS 


Introduction. 


Executive Summarj’ 3 

Exercise Design 5 

Purpose 5 

Scope 5 

Focus 5 

Structure 5 

Materials 6 

Guidelines ; 6 

Exercise Assumptions and Artificialities 6 

Scenario 7 


Exercise Objectives 8 

Significant Findings 11 

Coordination and Communication within Jurisdictions 1 1 

Technical Issues 1 ! 

Change in HSAS Threat Level 12 

Issues and Recommendations 13 


VDEM EOC * 13 

FEMA HQ 15 

DCEMA EOC 19 

FBI WFO f.. 22 

MEMA EOC L. 24 

USDHSNCR V. 27 


Appendix A - Exercise Participants 28 


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INTRODUCTION 

Background - The Face of Terrorism 


September 1 1, 2001, stands as a day that forever changed the way Americans view terrorism. 

The magnitude of the events shattered many long-held beliefs regarding the types of terrorist 
attacks the Nation might face, and has effectively shattered the image of “Fortress America” for 
many citizens. As former Senator Sam Nunn wrote shortly after the tragedy, “The terrorists who 
carried out the attack of September 1 1 showed there is no limit to the number of innocent lives 
they are willing to take. Their capacity for killing was restricted only by the power of their 
weapons.” 

As the Nation worked to recover from the attacks on the World Trade Center, on the Pentagon, 
and in western Pennsylvania, this statement proved to be prophetic, as cases of anthrax exposure 
began to appear around the country. Cases first appeared in Florida, then New York and 
Washington, DC, and then in various locations across the country. Although no one has claimed 
responsibility for the release of anthrax, the country remains on an overall higher state of alert. 
Security at buildings, airports, and other facilities has increased, and government officials warn 
of the danger of further attacks on the Nation. 

Many speak of a “new framework for national security” in which the fight against terrorism will 
take prominence. As President Bush stated on the first weekend after the attacks, “We haven’t 
seen this kind of barbarism in a long period of time. No one could have conceivably imagined 
suicide bombers burrowing into our society and then emerging all in the same day to fly ... U.S. 
aircraft into buildings full of innocent people. . .and show no remorse. This is a new kind ... of 
evil. And we understand. And the American people arc beginning to understand. This crusade, 
this war on terrorism is going to take a while. And the American people must be patient.” As 
the war on terrorism continues to take shape, the world remains anxious that the next outbreak of 
violence could come from any direction, at any time. 

As the country responds to and recovers from these attacks, citizens turn to political leaders with 
one question: “What will be next?” As the latest operations in the war against terrorism begin, 
the Nation’s leaders have reiterated the need for preparedness against all kinds of threats. Long- 
held taboos have been broken, and today’s terrorist has the potential to be far more deadly than 
ever before. The tools of the terrorist have evolved from pipe bombs and guns to massive 
ammonium nitrate bombs, the use of airliners as flying bombs, and the dissemination of anthrax. 

Extremist and absolutist ideologies allow perpetrators to take extraordinary measures in support 
of their goals. At the forefront of this in the international arena is al Qaeda, a group of Islamic 
militants led by Osama bin Laden. Having claimed credit for the September 1 1 attacks, bin 
Laden declared that more will occur. In recent years, he has stated that acquiring weapons of 
mass destruction (WMD) was a goal of his group. As President Bush said in November 200 1 , 
“These terrorist groups seek to destabilize entire nations and regions. They are seeking 


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chemical, biological, and nuclear weapons. Given the means, oiu" enemies would be a threat to 
every nation and, eventually, to civilization itself.” 

Because of this, the use of WMD by terrorists has received even greater prominence in the 
United States as a major national security concern. As Senator Nunn wrote. “We have had a 
look at the face of terrorist warfare in the 2 1 st century, and it gives us little hope that if these 
groups gained control of nuclear, biological, and chemical weapons they would hesitatetp use 
them.” ‘ .. 

In March 2002, the Office of Homeland Security (OHS) developed a national alert system that 
responds to concerns about terrorist attacks. This system disseminates information regarding the 
risk of terrorist attacks to all levels of government and tile Artieffcan people. 
There are five color-coded threat levels associated with the level of risk of 
terrorist attacks and what protective measures should be tak^. 

When confronted with the question of “What will be next?” leaders cannot 
say for sure. However, they reiterate that we as a Nation will be committed 
for the long term, that we must steel our resolve, and that we must endeavor 
to ensure that our communi^es'apftfls prepared as possible to respond to any 
future attacks. 

With that resolve in mind. The Homeland Security.Xct of 2002 was signed into law thus 
changing the OHS and creating the U^,J)epanmenf^fJUomeland Security (USDHS) which 
became operational on March 1, 2003.'. " 

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EXECUTIVE SUMMARY 

The National Capital Region Functional Exercise (NCRFE) was conducted on May 12, 2003, in 
the National Capital Region (NCR). This included the Federal Emergency Management Agency 
Headquarters (FEMA HQ) in Washington, DC; The District of Columbia Emergency 
Management Agency Emergency Operations Center (DC EMA EOC) in Washington. DC: the 
Federal Bureau of investigation Washington Field Office (FBI WFO) in Washington. DC; tlic 
Virginia Department of Emergency Management Emergency Operations Center (VDEM EOC) 
in Richmond, VA; and the Maryland Emergency Management Agency Emergeocy Operations 
Center (MEMA EOC) in Reisterstown. MD. and the U.S. Department of Homeland Security 
(USDHS), Office of the National Capital Region Coordinator (ONCRC) in Washington, DC. 

The exercise was conducted under the aegis of the USDHS, Office for Domestic Preparedness 
(ODP), in cooperation with the NCR. The NCRFE was designed lo coincide with the TOPOFF2 
(T2) full-scale exercise in order to assist the NCR jurisdictions in assessing their preparedness 
and coordination in response to a general attack on the Nation and changes to the Homeland 
Security Advisory System threat level. The T2 scenario involved a radiological dispersal device 
(RDD) explosion in Seattle, WA. The NCRFE was a no-fault, functional communications 
response to the weapons of mass destruction (WMD) icrrorism event in Seattle. WA, as well as a 
simulated but credible threat to the National Capital Region. The NCRFE was designed by the 
Community Research Associates (CRA) USDHS Exercise Support Team. 

The NCRFE scenario incorporated two events: a credible threat of a terrorist event directed at 
five U.S. cities and a radiological dispersal device (RDD) explosion in Seattle, WA, The 
exercise included two modules. In Module One (which was simulated as six days earlier. May 6, 
2003). the Homeland Security Advisory System (HSAS) national threat level was raised from 
Yellow to Orange. In Module Two, an RDD exploded in Seattle, with a subsequent change in 
threat level from Orange to Red. This functional exercise scenario allowed the jurisdictions to 
assess their overall communication and coordination within the National Capital Region. 

One of the exercise’s main objectives was to assess the relationship among all jurisdictions 
within the National Capital Region. Information-sharing and coordination proved to be 
extremely important in mitigating a terrorist event in 
the NCR. The DC EOC seemed to be controlling 
most of the flow of information to Maryland and 
Virginia. MEMA EOC representatives felt that other 
than a conference call, they were pulling information 
from the other jurisdictions, rather than having the 
information being pushed to them. Also, it was 
noted that it would have been beneficial to have 
representatives from FEMA, VA, and MD in the DC 
EOC during the exercise to further enhance the 
jurisdictions’ relationships. 



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Technical communications issues within each HOC proved to be an exercise obstacle but all 
jurisdictions were able to properly communicate with each other. FEMA HQ had issues with 
videoconferencing, although they noted that in a real-world setting, they would have had the 
Information Technology (IT) support they needed. The DC EOC had some technical problems 
with their internal E-Team software that supported their EOC traeking system. At VDEM EOC, 
sufficient security clearances were not available for the use of the secure video teleconferencing 
(VTC) system. Changes in homeland security require that a National Guard representative be 
present at all times that secure VTC equipment is being used. 

Overall, the exercise was very successful, PC EOC 
felt that they had good control of the situation, and that 
they were disseminating information efficiently. 
MEMA EOC felt that all of their olqcctives were met. 
but that exercise infonnation should have been 
disseminated more often (from the DC EOC). VDEM 
EOC needs more funding in order to participate more 
effectively in exercises. FEMA was very effective 
throughout the exercise in their role as the coordinator 
of Federal assets. USDHS*s new role of providing 
policy guidance and coordination for the NCR was 
accomplished without any problems. The only major question that was not addressed during this 
exercise was how well the communications network connection would work between the Federal 
agencies’ emergency relocation sites."' 



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EXERCISE DESIGN 


Purpose 


The National Capital Region Functional Exercise (NCRFE) was designed to coincide with the 
TOPOFF 2 (T2) full-scale exercise (FSE) in order to assist National Capital Region (I^€R) 
jurisdictions in assessing their preparedness and coordination in response to a general attack on 
the Nation and changes to the Homeland Security Advisory System (HSAS) th^t level. \ 

Scope 


4SAS) threat level. 


The NCRFE was conducted on May 12, 2003, at various locations wi^in the^^R, including the 
District of Columbia Emergency Operations Center (DC EOC), the State of Maryland EOC, the 
Commonwealth of Virginia EOC, the Federal Bureau of Investigation (FBH^ashington Field 
Office (WFO), the Federal Emergency Management Agency rf^dquarfers (FEMA HQ) at 500 
C. Street, and the Office of the National Capital Region CoordinatofTb.S. Department of 
Homeland Security (ONCRC, USDHS). Approximately 100 individuals participated in the 
exercise. 


Focus 



The NCRFE events focused on the following activities: 

• Observe or exercise NCR coordination functions. 

• Observe use of physical communications facilities. 

• Reinforce established policies and procedures. 

• Measure resource adequacy. 

• Assess inter-jurisdictional relations. 

The NCR^E'was^layed in real lime. However, some responses and actions required additional 
time or accelerated time in order to meet exercise objectives. 

Structure 


L/ 


The NCRI^^xamined the connectivity, in a free-play environment, of various NCR agencies as 
they relatedlio the exercise scenario. The NCR agencies that were represented are: 


• Virginia Department of Emergency Management 

• Federal Emergency Management Agency 

• District of Columbia Emergency Management Agency 

• Federal Bureau of Investigation — Washington Field Office 

• Maryland Emergency Management Agency 

• Office of the National Capital Region Coordinator, U. S. Department of Homeland Security 


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The NCRFE was designed as a 4-6 hour, multi-jurisdictional, weapons of mass destruction 
(WMD) functional exercise, held on May 12, 2003, in the NCR. It was conducted in conjunction 
with, but separate from, the T2 national WMD FSE. The NCRFE used and followed the T2 
scenario and background material to drive the exercise play. 

The NCRFE was designed to exercise individual capabilities, multiple functions, activities 
within a function, or interdependent groups of functions. It was generally focused on exercising 
the plans, policies, procedures, and staffs of the managerial or direction and control nodes of 
each jurisdiction’s emergency management agency. Generally, the use of respcmse resources 
was simulated, and events were projected through an exercise scenario and event updates to 
stress or drive activity at the management level. 

Materials 


A ciimprchensive set of exercise materials was developed, including an Exercise Plan 
(EXPLAN), Controller/Evaluator (C/E) Handbooks, a Master Scenario Events List (MSEL), and 
identification badges and hats. 

Each conlroller/evaluator involved in the execution of the exercise received a briefing prior to 
the exercise that described their duties and responsibilities in depth. They were provided with a 
C/E Handbook with detailed instructions about the exercise and the scenario, as well as their 
roles and responsibilities. Evaluation forms for each controller and evaluator were also 
provided. An EXPLAN was distributed that contained general information regarding basic 
issues, such as the purpose of the exercise and rules of conduct. 

Guidelines 


• The exercise was not a test, but rather a no-fault learning experience. 

• The exercise was intended to be in an open, low-stress environment. 

• This exercise served as a realistic setting within which participants were given the 
opportunity to implement previously identified adjustments in standard operating policies 
and procedures. 

• Responses were based on current capabilities (i.e., only existing abilities and assets). 

Exercise Assumptions and Artificialities 


A number of assumptions and artificialities were necessary to complete the exercise within the 
time allotted. 

Assumptions 

The following general assumptions applied to the NCRFE: 


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• The goals and objectives of the exercise were consistent with functional area operations, 
technical plans, and procedures, whenever possible. 

• NCR agencies, along with the USDHS Office for Domestic Preparedness (ODP) and/or its 
contractor (Community Research Associates [CRA]), were major participants and/or had 
significant roles in coordinating the exercise. 


Artificialities and Constraints 


Although there were a number of artificialities and constraints that may have d^racted 
exercise realism, the NCRFE planners and participants recognized an d acce ptedjthat^'me 
artificialities and simulations were necessary to carry out the exercise. 


lAthata 


\ 

ted from y 


Scenario 


Several variables were selected by the NCRFE planners and us« in the development of the 
scenario and overall structuring of the exercise: \ 

The NCRFE was connected with the T2 F^Tbiitl^^s played separately. 

Background intelligence events in Module Oi^trigpTgdta change in the HSAS national 
threat level from Yellow to Orange, 



• A WMD event involving an RDD in Seattl^^^A, in Module Two triggered a change in the 
HSAS national threat level from Orange to Red 

Module One. Module One l^^as p layed as^f it were May 6, 2003, and used the T2 background 
information that built up a credibjejterrprism threat against five major U.S. cities, triggering an 
HSAS threat level change from'Yellow to Orange. 

Module Twg^Module Two w^ played in real time on May 12, 2003, and focused on an RDD 
attack in S^eattl^WA, and the subsequent HSAS threat level change from Orange to Red. 




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EXERCISE OBJECTIVES 

NCRFE was designed to assist Federal, State, and local agencies located in the NCR in 
coordinating a response to changes in the national threat level, as a potential but credible region- 
wide threat of WMD terrorism evolves. Seven specific objectives for the exercise are listed 
below with comments: 

1 . Objective: Identify and exercise communication capabilities {voice, fax, data, and video) 
among NCR jurisdictions. 

Discussion: This major objective was clearly met during the planning and execution 
phase of the exercise. Voice, fax, and data connectivity worked fine among all of the 
players. However, technical communication issues within each EOC proved to be an 
obstacle. A video connection among all NCR jurisdictions is needed; not all jurisdictions 
had the proper equipment to have a video conference meeting. 

Recommendation: Each NCR jurisdiction needs to have its communications divisions 
review the requirements for full video conferences and establish the budget to gain the 
equipment and capability. 

2. Objective: Review information-sharing capabilities among NCR jurisdictions. 

Discussion: This objective was met by each player jurisdiction. During the course of the 
short exercise, information was passed among the organizations via voice, fax, and 
computer systems. Had the exercise lasted longer, the infonnation-sharing capabilities 
would have continued to improve. 

Recommendation: The NCR jurisdictions should continue to exercise their 
communications capabilities among the organizations on a day-to-day basis to ensure that 
each system works and that there is a continuing flow of information that is second nature 
to all involved in this ptrocess. This objective should be first and foremost in all future 
NCR exercises. 

3. Objective: Develop and coordinate consistent public information strategies. 

Discussion: This objective was addressed very carefully by each jurisdiction’s public 
affairs officer (PAO) before and during the exercise. Each PAO connected with his or 
her counterpart, and opened all channels of communication to ensure that the public 
information strategies were properly coordinated. Again, in a longer exercise, this 
function would have been exercised in depth. 

Recommendation : The PAOs of each NCR jurisdiction should maintain contact with 
each other on a regular basis in order to keep the lines of communication open year- 
round. 


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4. Objective: Review connectivity within and among NCR agencies in accordance with 
USDHS procedures. 

Discussion: Early in the exercise, all of the player NCR agencies made voice, fax, and 
data connections with their counterparts at all levels (policymakers and staff). Several 
telephone conference calls were made among the NCR agencies, but the use of radios and 
video conferencing was not tested. It should be noted that because of the short length of 
time for this exercise (and the scope of the scenario), the FEMA Interim Operating 
Facility (lOF) and the USDHS operations center were not used or tested in this exercise. 

Recommendation: The NCR should schedule a longer and more extensive NCR WMD 
response exercise in the near future, which will force the testing of all NCR emergency 
operations facilities (and communications) at the Federal, State, and local levels within 
the NCR. 

5. Objective: Coordinate the decision-making processes of all diree jurisdictions with 
FEMA and the FBI. 

Discussion: The decision-making processes of all three major NCR jurisdictions were 
completely coordinated with FEMA, the FBI, and USDHS. Each agency was connected 
to several senior-level conferenee calls, which ensured that the decision-making process 
was properly coordinated. 

Recommendation: The major NCR jurisdictions should ensure that the senior policy 
council members continue to meet on a regular basis, and hold at least one general 
teleconference each month to discuss a major policy issue. 

6. Objective: Review 7 of the NCR’s “8 Commitments to Action": 

Terrorism Prevention 

Citizen Involvement in Preparedness 

Decision Making and Coordination 

Emergency Protective Measures 

Infrastructure Protection 

Media Relations and Communication 

Mutual Aid 

Discussion: All of the Commitments to Action listed above received at least a review of 
required actions by each major jurisdiction during this exercise. The stated goal of the 
exercise was to follow the elevated threat level recommendations of USDHS (based on 
the T2 threat scenario), and review the coordinated actions that need to be taken in the 
NCR for these areas of concern. Each jurisdiction understood many of the required 
actions, but because of the short length of the exercise, it was impossible to completely 
test each of these rather complex subjects. 


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Recommendation: The NCR should take at least three months to plan a longer and 
more specific exercise that will allow a thorough testing of each of these important 
aspects of a coordinated response to a terrorist WMD attack on the region. This type of 
exercise should run about 8 to 12 hours in length. 

7. Objective: Improve the NCR’s readiness to respond to any possible act of terrorism. 

Discussion: Every practice exercise that can be conducted before a real event occurs 
improves the readiness of an organization, agency, government, or region to respond to a 
real incident. This exercise was the first step in that readiness improvement process for 
the NCR region. Most State-level governments and military organizations believe that 
daily and weekly individual/small organizational training, followed by quarterly or 
biannual large organization training or exercising, is the propa: way to prepare an 
organization or agency for the real event. The NCR jurisdictions should do no less. 

Recommendation: The NCR Senior Policy Council staff should prepare a three-year, 
region-wide exercise plan and schedule that can be funded and followed to improve the 
NCR jurisdictions' preparations for a terrorist WMD attack on the region. Most experts 
in this field truly believe that it is not a matto' of “if ’ but “when" an attack will occur on 
the very high-profile District of Columbia and consequently the NCR. 



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SIGNIFICANT FINDINGS 

Coordination and Communication Among Jurisdictions 


Before the NCRFE took place, a major concern was the communication and coordination among 
all NCR jurisdictions (MD, VA, DC, FEMA, USDHS-NCR) in a terrorist event. Although the 
NCR was not an imminent target for a terrorist event in the exercise, it was understood that being 
in or near the Nation's capital, as well as having a credible threat to five U.S. cities, required 
proper action (i.e., communication and coordination among all jurisdictions) in order to protect 
its citizens. Since the NCR comprises several jurisdictions, it was imperative to assess and 
enhance their communication and coordination effectiveness during a terrorist event. 

• It seemed that the District of Columbia Emergency Management Agency (DC EMA) was 
controlling most of the flow of information to the other States (MD and VA). 

• The Maryland Emergency Management Agency (MEMA) had the most difficulty with 
communication and information sharing during the exercise. Conference calls were 
established that included FEMA, USDHS, MD, VA. and DC. It seemed that there was little 
independent information sharing that took place outside of the conference call format. At no 
time outside of the prearranged conference calls was DC or VA queried as to how they were 
handling these issues of concern. 

• Representatives from FEMA, VA, and MD were not present in the DC EOC during the 
exercise. It was stated, however, that in a real-world setting, representatives would be 
present. 

Technical Issues 


There were a number of technical issues in each EOC that appeared to hinder the ability of the 

exercise participants to play efficiently. 

• At FEMA HQ, video conferencing was inaccessible during the exercise due to technical 
problems. 

• At DC EOC, computer printers were overloaded; exercise participants were kept waiting for 
their printed material. The location of the printers also obstructed the view of the Operations 
Chief The location of the printers also made it difficult for the participants to move freely 
throughout the DC EOC to gather information. 

• The DC EOC also had difficulties with the new E-Team Software, although Information 
Technology (IT) representatives were present to help with any problems that participants 
encountered (such as with training). 


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• At VDEM EOC, sufficient security clearances were not available for the use of the video 
teleconferencing system. Changes in Homeland Security policy required that a National 
Guard representative be present at the VDEM EOC each time that secure VTC equipment is 
being used. 

It is understood that technical issues are ubiquitous and difficult to avoid, and during a real-world 
situation, things would have gone differently. However, it should be stated that IT support should 
be available and proper clearances ensured, in order to enhance communication among 
jurisdictions. Coordination and communication were exercised well, and all participating 
agencies understood that they could be improved. 


Change in HSAS Threat Level 






The HSAS threat level change is a recommendation for each State. Following the HSAS threat 
level change from Orange to Red after the event in Seattle, questions arose in MEMA and 
VDEM regarding whether it was necessary to change the threat level throughout their entire 
State(s). 

• Following the terrorist event in Seattle and subsequent change in threat level from Orange to 
Red, FEMA immediately responded by activating and dispatching the NCR ERT-N to an 
emergency relocation site in Maryland, and was kept apprised of all actions thereafter. 

• VA controllers noted that VDEM EOC staff verbally questioned whether the entire State 
should be elevated to threat level Red. 

• MD controllers had a lengthy discussion regarding whether the entire State of Maryland 
should elevate the threat level to Red, or just raise the level within selected vulnerable 
jurisdictions. MD controllers also noted that the MD decisionmakers recognized distinct 
liability issues associated^with this decision. 



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ISSUES AND RECOMMENDATIONS 

Virginia Department Of Emergency Management 
Emergency Operations Center 

Richmond, VA 

General Statement 

The initial information and injects were handled well by the EOC staff. Appropriate notificatiojis 
to State agencies and the Governor’s Office and external notifications by fax and the VPEM 
EOC web site were made. All State agencies were notified within ten mtnuies of the beginning 
of the exercise. 


sm 

EMERGENCY OPERATIONS CENTER 

VkgiiBBipartment of Emergency Manegemwit 


The State Police cornplcx Aat houses the EOC was 
locked down, one point of entry was established, 
and mandatory ID use was instituted. The EOC 
paged the Commonwealth Preparedness Working 
Group (CPWG) for a conference call, which look 
place at 1 :32 p.m. The CPWG conducted a well- 
cffganized conference call with State agencies, and 
used a checklist for those agencies that were 
identified to participate in the call. A status review 
by each agency director was given, as well as the 
current condition of the EOC. 


As exercise play continued in the NCR. FEMA began notifying area representatives. Ms. Cindy 
Causey, the VDEM NCR field representative, was notified of the incident by FEMA directly on 
her cell phone. No additional notifictUions were made to the VDEM EOC. Dual notification 
should be done by FEMA. however, to ensure that the appropriate agency representative is 
notified. 

During the exercise, it was requested that a video conference call be held among the VA. MD. 
and DC EOCs. The Virginia EOC cannot open a secure VTC until a National Guard 
representative is presOTt. The VDEM EOC staff is still undergoing new security clearance 
investigations. 

During exercise play, the VDEM EOC communications center underwent a scheduled dispatcher 
shift change. Shift change briefings were conducted and there were no noted problems. 

All tasks and requests presented to VDEM EOC staff were handled in a timely and appropriate 
manner. Coordination on the State level was excellent. Policies and procedures are in place that 
identify tasks associated with an EOC standup. State coordination activities, and regional 
coordination activities. 


Overall, the VDEM EOC handled the scenario extremely well. 


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Specific issues identified at the VDEM EOC: 

• FEMA notification to VDEM NCR representative 

• VDEM EOC secure video communications 

• EOC facilities 

Issue: FEMA Notification to VDEM NCR Representative 

Observation: During the exercise, FEMA placed a cell phone call directly to Cindy Causey, the 
VDEM NCR field representative. Although this call was handled appropriately and showed the 
local coordination between VDEM and FEMA, if Ms. Causey had not been available or if her 
phone had been out of a service area, no one at VDEM would have been notified. 

Recommendation: VDEM EOC should develop a policy that provides all agencies with the 
centra! communications phone number for all emergency-related issues. This will funnel all 
communications directly to the EOC, who can then pass that information on to the appropriate 
person. 

Issue: VDEM EOC Secure Video Communications 

Observation: VDEM EOC has the capability and equipment to use a secure video 
teleconferencing system. Because of changes in Homeland Security policy, existing security 
clearances of the staff were removed and new clearances are still being investigated. 
Consequently, a National Guard representative must be present at the VDEM EOC each time 
that secure VTC equipment is being used. 

Recommendation: Security clearances should be expedited to allow the immediate use of 
secure VTC equipment. 

Issue: EOC Facilities 

Observation: As a key member of the NCR, Virginia is home to many critical Federal facilities, 
such as the Pentagon. In this new day of heightened security, and the need to handle complicated 
and specialized emergency coordination activities, the VDEM EOC is a small and outdated 
facility. Satellite video downlink capability was not available during the NCR functional 
exercise. 

Recommendation: Although engineering drawings are available to demonstrate the potential of 
a new VDEM EOC, there is currently no funding for construction. Construction should be a 
priority, however, and the availability of Federal funds should be investigated. 


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Federal Emergency Management Agency 

Headquarters 

Washington, DC 


General Statement 

The NCRFE was designed to allow the principal 
jurisdictions of the NCR (DC. VA, and MD) to 
exercise their communications and decision-making 
coordination during an elevated threat of terrorism that 
uses WMD in or near the NCR. This process had to be 
tied into and coordinated with the actions of key 
elements of the Federal Government, or in this case, 
the FBI, FEMA. and USDHS. 

The major issue facing the entire exercise was: Could 
these major jurisdictions communicate and coordinate 
what they were doing to protect their citizens, infrastructure, and communities with each other 
and the Federal Government in an eflective nwiner? Traditionally, FEMA. the FBI, and the 
governments of the three major jurisdictions (VA, MD, and DC) have learned to communicate 
and coordinate through their emergency management agencies during times of crisis response to 
disaster-related problems. This has resulted in a foundation upon which the current process is 
being built. USDHS is the only new player in this process, and is quickly integrating its 
organization into the control of the response system. The NCRFE showed that this system will 
work and that the major objectives were met (as well as possible in a four- to five-hour 
functional or command post exercise). 

The individuals representing FEMA during NCRFE did a superb job. The Federal Coordinating 
Ofllcer (FCO) (Mr. Davies) was acutely aware of FEMA’s roles and responsibilities and was not 
afraid to make recommendations and decisions when called for by the exercise scenario. He and 
his team analyzed the information as it was received, decided on what course of action was 
indicated and prudent, and then either implemented it or recommended to his superiors that it be 
implemented. The communication and coordination among FEMA. USDHS, and the NCR 
ECXils was outstanding. 

Specific issues identified at FEMA: 

• Location of NCR crisis management staffs 

• Relationship between USDHS and FEMA during this type of crisis management 

• Change in threat level from yellow to orange 

• Coordination and information sharing within the NCR 

• Press inquires to FEMA 

• Fax directing that all States be informed of the threat level change and specific actions 

• Post-Seattle blast actions 



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• Virtual News Network (VNN) broadcasts 

• Actions taken after RDD was confirmed in Seattle, and change in threat level from orange to 
red 

• Video conference 

Issue: Location of NCR Crisis Management Staffs 

Observation: Although FEMA has an Interim Operating Facility (lOF) located near the NCR 
(that is in effect a Federal EOC that is designed to give the Federal Government a location from 
which to operate and communicate during an emergency), it was not used for this exercise. 
FEMA and USDHS were correct in believing that the NCR was reacting to a scenario that 
presented a “credible threat” to the area, although the actual attack was on another part of the 
country. Both elements of the government would have been operating (at least during this 
exercise) from their regular offices. 

Recommendation: During future NCR exercises, the Federal Government should exercise the 
lOF so that DC. VA. and MD can gauge any problems they may have in dealing with that 
specific location (concerning communications, etc). If the lOF had been used for this exercise, 
the other players (VA, DC, and MD) might have had a better idea of whether they would have 
trouble communicating with the Federal Government at that location during this type of crisis 
response/coordination. 

Issue: Relationship Between USDHS and FEMA During This Type of Crisis Management 

Observation: Although the relationships are still being developed, the new laws and 
Presidential Directives are quite clear on the relationships and responsibilities of both agencies. 
USDHS (through the Office of the NCR Coordinator) has policy and Lead Federal Agency 
(LFA) responsibility for the NCR. FEMA has the same responsibilities that it has always had, 
and that is to coordinate the Federal response to the consequences of any type of disaster within 
the region. The only difference is that the USDHS is acting as the LFA on major decisions that 
are coordinated with the other State-level Jurisdictions. It should be noted that both the USDHS 
and the Federal Coordinating Officer (FCO) for FEMA did an excellent job of coordinating their 
actions and responsibilities during this exercise. Both Mr. Ken Wall (USDHS) and Mr. Tom 
Davies (FCO, FEMA) did an outstanding job of fulfilling their roles during this exercise. 

Recommendation: The NCR jurisdictions should continue to conduct a wide range of exercises 
that will prepare and train the entire region in the complex requirements of coordinating all of the 
government actions required to protect the NCR community from a WMD terrorist attack. 

Issue: Change in Threat Level from Yellow to Orange 

Observation: The FEMA team took the time to discuss options and actions based 

on the information regarding the change in threat level, and took the following actions: They 

simulated calls up their internal chain of command to make recommendations 


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and to seek guidance. They simulated alerting all members of the NCR Emergency Response 
Team - National (ERT-N) of the change in threat level. The ECO ordered his staff to conduct a 
communications check with all NCR EOCs. This was actually done at 1 : 1 5 p.m., with no 
prompting. The FCO also had his staff begin keeping a log of all activities. 

Recommendation: None. Based on the available information, the FEMA FCO and his staff 
took proper actions. 

Issue: Coordination and Information Sharing Within the NCR 

Observation: The first of several NCR conference calls occurred at approximately 
1 :35 p.m. Participants included the senior leaders of the NCR and FEMA. Available 
information and intelligence were shared and options for action were discussed and coordinated. 
In response to an injected fax from USDHS, the FEMA FCO stated that xmdcr the circumstances 
outlined in the scenario, FEMA would be represented in the DC EMA EOC in a real-world 
setting, 

Recommendation: During all future exercises, FEMA representatives in NCR EOCs should be 
able to act on behalf of their respective organizations (decisionmakers). 

Issue: Press Inquiries to FEMA 

Observation: The FCO fielded the press inquiries himself; to help ensure a coordinated 
message, he referred the press to USDHS for comment. This was the correct response both 
operationally and politically. He clearly understood the importance of a coordinated press 
release. 

Recommendation: Each NCR jm^s officer should continue to develop coordinated NCR media 
response plans. 

Issue: Fax Directing That States Be Informed of Threat Level Change and Specific Actions 

Obser\'ation: The FCO spoke with his chain of command by phone and recommended that the 
NCR Management Cell be deployed to the appropriate NCR locations as a precautionary 
measure. He also recommended that the Region 3 Regional Operations Center (ROC) stand up. 
He had previously notified all FEMA regions of the change in threat level before being prompted 
by the fax. 

Recommendation: None. All proper actions were implemented. 

Issue: Post-Seattle Blast Actions 

Observation: The FCO took part in another NCR senior leaders conference call and simulated 
conversations with his chain of command. He also had conversations with USDHS in which he 


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recommended deployment of the entire NCR ERT-N team. He ordered his staff to ensure that the 
Continuity of Operations (COOP) site is fully “warm” and that they conduct a communications 
check with units in the COOP. 

Recommendation: None. 

Issue: VNN Broadcasts 

Observation: Unfortunately, the FEMA representatives taking part in the exercise could not 
hear the broadcasts because the sound on their PCs did not work, and they did not have control 
of the volume on the big screen. 

Recommendation: Technical support should be available in future exercises to ensure that all 
participants have the ability to hear what is going on. 

Issue: Actions Taken After Seattle ROD Confirmed and Change in Threat Level from Orange to 
Red 

Observation: The FCO, in concert with USDHS and the FEMA chain of command, activated 
the NCR ERT-N to the emergency relocation site in Maryland. Other pertinent EST activations 
were also considered so that units would be operational BEFORE an event occurred in the NCR. 
FEMA operations would have moved to their lOF so as to be out of the DC area prior to an 
event. FEMA regions and NCR EOCs were kept apprised of actions taken by FEMA. 

Issue: Video Conference 

Observation: FEMA representatives were unable to access video conferencing during the 
exercise due to technical problems. The FCO instructed his staff to ensure that all necessary 
names and phone numbers of points of contact (POCs) are available for real emergencies. He 
stated that in the real world, he would have had the technical support he needed to take part in 
the video conference. 

Recommendation: Proper video communications support should be made available to all key 
NCR facilities before the next scheduled NCR exercise. 


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District of Columbia Emergency Management Agency 
Emergency Operations Center 
Washington, DC 


General Statement 

The District of Columbia Government and EMA worked collectively with several other EGCs to 
exercise their plans. This exercise proved to be beneficial to the DC government and the DC 

EMA. The DC EMA stood up all Emwgency 
Support Functions (ESFs), even though a few 
agencies either reported late Mr feiled to report. 

The controllers witnessed DC EOC participants 
working very weU with each other and within their 
respective ESFs. Information was passed among 
agencies in a proper and respectful manner. Most of 
the participants understood and perfonned their roles 
in the DC EOC. These same participants carried out 
their respemsibilities as they were instructed and as 
they had practiced in previous training exercises. 

In the beginning of the exercise, the leaders of the DC EOC appeared to be somewhat loose with 
the management of the operations. As the exercise progressed, they gained and maintained 
control of the exercise EOC staff. The only iccomroendalion that can be olYered is to practice, 
practice, and practice. 

Specific issues identified at the District ofColumbia EOC: 

• Unfamiliarity of the neW E-Team Software 

• Technical Issues 

• SecuriQf 

• Public Information 

• Reports from ESFs^ 

Issue; Lack of Familiarity With New E-Team Software 

ObservatioDt Several of the participants in the DC EOC appeared to be having difficulty using 
this software, at least in the beginning of the exercise. Prior to the start of the exercise, a special 
training session on using the new software was held in the EOC. Not all participants in the DC 
EOC were present for this training. 

Recommendation: Training for participants who will use this software in the future should 
have been held several days before the exercise. The DC Information Technology section 
provided several staff members to assist with questions and problems as they arose. The 




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participants should have been given more time to learn and experience the advantages of the 
software prior to using it during a real or simulated terrorism event. 

Issue: Technical Issues 

Observation: Many participants were forced to wait for data from HOC printers. In many cases, 
this is a trivial issue. During this exercise, however, many participants were waiting for printed 
copies in the area where the Operations Chief and his staff were trying to manage the situation. 
People standing in this area tended to cause several problems: obscuring the Operations Chiefs 
ability to see the participants and the information displayed on the video screen(s); distracting the 
Operations Chief and/or his staff by the conversations being held; and the ability of other 
participants to move freely through the DC EOC to gather information. 

Recommendation: There should be more than one printer for 45 workers in the DC EOC. This 
printer(s) should be located close to the ESF areas without obscuring the vision of the Operations 
Chief and/or staff, and where they will not interfere with the flow of traffic through the DC EOC. 

Issue: Security 

Observation: During the exercise, many observers passed through the main area of the DC 
EOC. The majority of these observers were local dignitaries and/or VIPs of the DC 
Government. The process for checking the identification of all persons entering the EOC 
appeared to be in place, but many of the visitors were not checked against an “authorized access” 
list. 

Recommendation: Implement a more visible method of indicating that security checks were 
performed and a person has been cleared to enter the sensitive area. The liaisons for each of the 
ESFs should be able to quickly determine if a person/observer has the proper credentials to be in 
the EOC. This ensures safe operations of each ESF Liaison. 

Issue: Public Information 

Observation: The DC EMA public information officer (PIO) and staff appeared to be very busy 
dealing with the visiting dignitaries. Their participation in the exercise appeared to be minimal. 

Recommendation: It is understood that when a real-world situation is unfolding in the DC 
EOC, the visitors will not be in the DC EOC. This should free the PIO and her staff to perform 
those duties as identified in the DC EOC protocols. 

DC EOC needs to identify a location where joint regional information can be obtained and 
verified, briefings can be developed, and contacts can be directed regarding the event(s). The 
contact information and location of this Joint Information Center (JIC) should be provided to all 
participants in the DC EOC and the surrounding EOCs. Information to the public and the news 
media regarding the safety of the public is very critical during an incident. 


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Issue: Reports From ESFs 

Observation: Hourly reports were requested from the ESFs. Several, not all, of the ESFs were 
able to give their reports. There appeared to be two reasons for this: the importance of the ESF 
for the particular timeframe, and not enough time allotted for each ESF to make a report. 


Recommendation: Three methods could be implemented to deal with this observation. First, 
develop a template of what information needs to be reported by each ESF; second, through 
analysis of past exercises, determine which ESFs need to report during a particular work 
period(s) — develop a checklist to help the DC EMA Operations Chief and/or his staff to manage 
these reports. Third, set timeframes for the presentation of the ESF reports, and have the ESFs 
practice making reports in that timeframe. 




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Federal Bureau of Investigation 
Washington Field Office 
Washington, DC 


General Statement 

For pragmatic reasons, the participation of the NCR in any TOPOFF exercise is indispensable. 

In any incident, whether natural or man-made, the resources of the Federal Government will 
require some time to respond and arrive at the scene of an incident. These resources, in the form 
of personnel and assets, are critical to the preservation of life and the restoration of important 
infrastructure. This is particularly true when the incident{s) involves terrorists and the use of 
WMD. 

An exercise of the magnitude of T2, with the participation of thousands of individuals (elected 
and appointed; State, county, and municipal; crisis and consequence responders), jurisdictions 
within the continental United States, and international implications, necessitates the 
consideration and active involvement of the NCR. The NCR is the keystone to most if not all of 
the Nation’s central databases; it serves as the conduit for national, regional. State, and local 
representation and decision-making; it is positioned to activate and dispatch specialized 
personnel and vital assets to affected areas; it is central in the gathering and dissemination of 
information and intelligence throughout the United States and internationally; and as the seat of 
national government and host to commercial associations, nongovernmental organizations, and 
countless other entities, the NCR is directly or indirectly impacted by events that occur anywhere 
in the United States and its territories, and even in other countries. Therefore, the NCR should 
be integral in all aspects of the TOPOFF exercises. 

The participation of the NCR in T2 was not integral and its presence was an afterthought, which 
short-circuited many of the operational procedures that normally take place. The results were 
confusion, miscommunication, misdirection, and ineffective action. The participation of the FBI 
WFO is a case in point. It was tasked with the role of performing and executing functions that 
are not within its normal realm, which contributed to actions inconsistent with proper 
procedures. As expected, this resulted in questioning of the value of the exercise. 

In atidition to the pragmatic reasons for NCR involvement, there are also symbolic reasons, such 
as conveying the command and control of the government by representative leadership. The 
functioning of the government’s departments and agencies is a statement of the stability of the 
government 

Specific issues identified at the FBI WFO; 

• National exercise participation 

• Generation of exercise intelligence 

• Communications and intelligence release 


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Issue: National Exercise Participation 

Observation: The NCRFE was based on the events of T2, but NCRFE participants were not 
permitted to intermingle with T2 players. Due to the very nature of the NCRFE, participating 
agencies raised questions and concerns regarding T2 events and intelligence generated at the 
Seattle, WA, Incident Command. Because additional exercise information was not available, the 
FBI WFO was forced to break with NCRFE communication protocols and contact the Strategic 
Information and Operations Center (SIOC) regarding Seattle incident intelligence, and pass this 
information on to all participating agencies. 

Recommendation: FBI WFO, National Capital Response Squad (NCRS), recommends that 
future National Field Training Exercises (FTXs) have either the full partici^tion of all agencies 
involved without limits on communications, or no participation at alllin the FTK. Limiting 
agencies’ participation is counterproductive and unrealistic during a trug^WMErevent. 


Issue: Generation of Exercise Intelligence 




Observation: A raw intelligence product was developed for the T2.cxercise and provided to the 
WFO FBI as part of the NCRFE. WFO was participating as both F^ HQ/SIOC and the FBI 
Field Office, and did not have sufficient lime^^igenerate a working intelligence product to 
release as exercise intelligence for the initiation o^^iSREE. 

Recommendation: Increased preparat ion ti me for PBLanalysts would allow for generation of a 
useful intelligence product. This Droductcaul d.th en be disseminated to relevant State and local 
agencies for use in asset deployment and event evaluation. 


Issue: Communications and Intelligence Release 

Observation: Communication among exercise controllers and the release of exercise 
intelligence needs to be re-evaluated. Allowing the intelligence products to control the exercise 
actions is a realistic scenario. However, by providing all NCRFE participating agencies with the 
same intelligence product at the same time through exercise controllers defeats the nature and 
objectives of the NCRFE exercise. Appraising the command and control issues among the 
various agencies is nullified by this action. 

Recommendation: FBI WFO NCRS recommends that the agency responsible for generating 
the intelligence should control the product and disseminate the information accordingly. 


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Maryland Emergency Management Agency (MEMA) 
Emergency Operations Center 
Reisterstown, MD 


General Statement 

As part of the NCRFE, MEMA sought to evaluate its own 
processes and capabilities while engaged in a simulated 
domestic security incident of significant scope. 

Representatives from various relevant Maryland ageneics 
were present, and the participation level from all players 
was high. 

Representatives from the State of Maryland participated in 
the exercise primarily from a conference room area located 
within the State of Maryland EOC, and all injects were 
received there and disseminated to the participants around the table for (liscussion. This design 
led to a cooperative information-sharing environment and was a benefit to the exercise 
participants. The State of Maryland was also able to use a secure video conference capability 
that was shared with DC and VA, which would have been critical for any necessary secure 
teleconferences. Unfortunately, due to technical problems with some outside systems, the video 
interface was minimal. However, the Maryland EOC was able to receive the VNN live feeds that 
originated from the State of Washington, wliich was invaluable for information acquisition, 
enhancing the exercise as a whole. 

The Stale of Maryland participated to the fullest extent in a highly effective functional exercise 
environment, and some very significant issues were brought to the surface throughout the day. 

Specific issues identified at the Maryland Emergency Operations Center: 

• Regionalized domestic security threat condition change 

• Information sharing among the NCR jurisdictions 

• “Essential Employee” designation 

Issue; Regionalized Domestic Security Threat Condition Change 

Observation: A critical issue of concern that Maryland had throughout the NCR exercise dealt 
with the shifting of domestic security threat level conditions. Questions arose from the State 
about whether it was a USDHS requirement for Maryland to issue a statewide threat condition 
elevation, or whether that threat condition could be elevated regionally, i.e., affecting only the 
NCR jurisdictions. Maryland stated that a series of required security and legislative protocols 
would be put into effect if the domestic security threat level condition is raised to red, and that 
the State should have the ability to regionalize the threat level elevation to include the areas of 
highest vulnerability, but not be so inclusive as to prohibit “normal” operations statewide in 



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areas of lesser vulnerability. Maryland did recognize through its discussions that there is a 
distinct liability issue, as well as a reliance on other jurisdictions and cooperative efforts, that 
exist within the NCR jurisdictions. Decisions for the State of Maryland would not be made 
without, at the very least, consultation with the DC and VA. 

Recommendation: It was clear that this issue needs to be examined further. Consider a 
collaborative panel discussion or workshop with representatives from the NCR jurisdictions; the 
State of Maryland; the State of Virginia; the District of Columbia; USDHS; and other relevant 
regional and Federal partners and stakeholders, with regionalized domestic security threat level 
condition change as the principal subject for discussion. 

Issue: Information Sharing Among the NCR Jurisdictions 

Observation: During the NCRFE, there was a minimal level of information sharing and 
collaboration among the NCR jurisdictions within the allocated response timeline presented in 
the scenario. The sharing of information was primarily done through pre-scheduled conference 
calls in which all relevant jurisdictions and Federal agencies participated. The conference calls 
were facilitated by USDHS and primarily dealt with global issues relevant to all involved. There 
was very little independent information sharing that took place outside of the conference call 
format. The State of Maryland struggled with some critical issues throughout the afternoon that 
were presented to them as a result of the exercise events. Similar issues were likely encountered 
within the other participating NCR jurisdictions as well, but at no time outside of the pre- 
arranged conference calls was DC or VA queried as to how they were handling these issues of 
concern. This observation goes both ways: neither NCR jurisdiction reached out to the State of 
Maryland to discuss situations or share infonnation during the exercise. As critical regional 
partners, the sharing of information is essential to a coordinated and effective response. 

Recommendation: Continue to foster a regional relationship with DC and VA as NCR partners 
through exercises and training such as the NCRFE. Continued collaboration and partnership in 
training, exercises, and plan development only enhances the NCR’s overall level of domestic 
preparedness. 

Issue: “Essential Employee” Designation 

Observation: There was a great deal of discussion among players about Maryland’s current 
“essential employees” list. This list was designed to address the State’s critical employee needs 
in the event of an emergency triggered by a natural disaster. It lists those employees who would 
be required to report to work despite a situation that would warrant the closing of government 
offices. Players noted that this list may not accurately reflect the State's employee requirements 
in the event of a domestic security threat or act of terrorism. There was some discussion as to 
how this situation could or should be resolved. Also, players discussed how, exactly, such an 
order would be carried out on a statewide basis. That is, would a domestic security disturbance in 
the Washington, DC, or Annapolis area necessitate the closing of government offices in other 
regions? The question remains: how should the recommendation be written to reflect these 


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needs? In many ways, these discussions mimicked those that players had about the elevation of 
the NCR threat level on a regional vs. statewide level. 

In addition, players discussed the financial ramifications of such a move and what variables 
would allow the State to be (or not be) reimbursed. For example, would a liberal leave or 
administrative leave be the best financial approach for the State? Would the State be 
compensated under a Code Red threat level? 

Recommendation: This is by no means a “simple fix" problem, and will require a concerted 
effort and meaningful discussions to resolve. Representatives from all primary State agencies 
should formulate an idea of what types of personnel would be necessary in the event of a terrorist 
attack or other domestic disturbance. Employee lists unique to each region may very well be the 
best approach. 

Anything that can be clarified immediately, however, should be. Fw example, a clear 
understanding needs to be reached between the Federal Government and Maryland as to what 
employee expenses, if any, are reimbursable. This is a particularly acute problem if there is an 
expectation that all NCR jurisdictions will react to the same threats in the same manner, 



LIMITED DISTRIBUTION 


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National Capital Region Functional Exercise 
DRAFT After-Action Report DRAFT 


U.S. Department of Homeland Security 
National Capital Region 
Washington, DC 


General Statement 

The USDHS, ONCRC was actively involved in the exercise and participated in their role in 
providing policy guidance and coordination for the NCR jurisdictions. This aspect of the 
exercise went very smoothly. 

Unfortunately, the actual NCR Coordinator was detailed to Seattle for T2, so his deputy 
participated in the exercise and did a great job. In the future, it might be beneficial for all 
principals to participate in these types of exercises. 

The Deputy NCR Coordinator operated out of his offiee, as this is where he would begin during 
an actual incident until the time that the Federal agencies’ relocation sites were activated. In 
future exercises it would be beneficial to take the scenario to the point where these sites are 
activated so that agencies can adequately assess how.th is process will occur, as well as the ability 
to effectively communicate with one another. 

Specific issues identified at the USDHS: 

• Coordination and Policy Guidanc^ 

• Communication and Coordination witI7i3tiiet.NCR Jurisdictions 



Issue: Coordination and Policy Guidance 

Observation: Providing policy guidance and coordination for the National Capital Region is a 
new role for the U.S. Department of Homeland Security, and it was accomplished without any 
problems. The Deputy Coordinator has a good understanding of what actions he needed to take 
in order to provide the necessary information to the NCR jurisdictions. 

Recommendation: Conduct more NCR response exercises to further improve new working 
relationships. 

Issue: Communication and Coordination with Other NCR Jurisdictions 


Observation: The Deputy Coordinator was actively involved in all conference calls that took 
place during the course of the exercise between the Federal agencies and the NCR jurisdictions. 

Recommendation: As noted by the Maryland EOC evaluator, more direct communications 
between NCR jurisdictions is needed in future NCR exercises. 


Page 27 


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National Capital Region Functional Exercise 
DRAFT After-Action Report 


APPENDIX A 

EXERCISE PARTICIPANTS 


DC EOC 


I DC WASA 
I DC WASA 

1 u sss 

(dh6) IG.U. 


(bK6) 


(D)(6) 


(b)(6) 


(b)(6) 


(b)(6) 


(b)(6) 


G.U. 

G.U. 

JUg. u. 

G.U. 

DC O.C.T.O. 

DC WASA 
MDW 


(b)(6) 


(D)(6) 


C Hospital Association 

^5^5^W 


DC DPW 


(b)(6) 

DC FO 

(b)(6) 

DC FO 


(b)(6) 


HAWDC 


Ghermay Aranga, O.C.T .O. 


(b)(6) 

DC Fire 

(>^H6) O.C.T.O. 


(b)(6) 1 GWU 

(b)(6) 

DCMA 


G. Bryan Jones, DHS/PHS Region Hi 


(b)(6) 

EMA 

(D)(6) 

OPM OSKA 

(b)(6) 

OCP/PSC 

(b)(6) 

PEPCO 

(D)(6) 

FPS-DHS 

(b)(6) 

MPD-SOD 

(b)(6) 

USCP 

(b)(6) 

DDOT 

(b)(6) 

To.c.t.o. 

(b)(6) 

DDOT 

(b)(6) 

DCNG 

(b)(6) 

DC WASA 

(b)(6) 

DC WASA 


DRAFT 


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National Capital Region Functional Exercise 
DRAFT After-Action Report 


MD EOC 


Don Keldsen, MEMA 
DHMH 


(b)(6) 


(b)(6) 


(b)i6) 


(b)(6) 


(b)(6) 


(b)(6) 


(b)(6) 


(b)(6) 


(b)(6) 

(b)(6) 


MEMA 
vflEMSS 
MSP 
MSP 
MDE 
MEMA 
MEMA 
MEMA 
MEMA 


)b)(6) 


(b)(6) 


MSP 


(b)(6) 


(b)(6) 

MET 


ICity of Annapolis 
JvlEMA 


MEMA 


(b)(6) 

DHMH 

(b)(6) 

MOOT 

(b)(6) 

DHMH 

(b)(6) 

DHMH 

MIEMSS 

(b)(6) 


VA EOC 


(b)(6) 


(b)(6) 


(b)(6) 


VDEM 
VDEM 
VDEM 



Dawn Eischen. VDEM 

VDEM 


(b)(6) 


(b)(6) 


VDEM 


FBI-WFO 



DRAFT 


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National Capital Region Functional Exercise 
DRAFT After-Action Report DRAFT 




LIMITED DISTRIBUTION 


Page iO 



T2AAR 


T2 


TOP OFFICIALS (TOPOFF) 
EXERCISE SERIES: 



September 30, 2003 


TOPOFF 2 (T2) 
After Action Report 
ANNEX D 


Information contained in this document is intended for the exclusive use of T2 Exercise Series 
participants. Material may not be reproduced, copied, or furnished to non-exercise personnel 
without written approval from the Exercise Directors. 



T2AAR 


T2 




For Off i c i a l Us e On l y 


'Wi 



1 








o 

TOPOFF2 Cyberex 


After Action Report 

July 2003 




Institute for Security Technologies at 
Dartmouth College 


1 




TOPOFF2 Cyberex - After Action Report 


r\ 







Technology Studies). All rights Reserved. Supported under Award number 2000- 
DT^feX-KOO 1 from the Office for Domestic Preparedness, Department of Homeland 
Security. Points of view in this document are those of the author(s) and do not 
necessarily represent the official position of the U.S. Department of Homeland 
Security. 



TOPOFF2 Cyberex - After Action Report 


Table of Contents 


Section 


1 Executive Summary 

2 Tasking 

3 Stakeholders 

4 Seminars 

5 Simulation 

6 Exercise Design 

7 Game Play 

8 Observations 

9 Recommendations for TOPOF: 

Appendix 

A Problem Chains 

B Master Scenario Event Listing (MSEL) 

Sample Simulation Communications Output 
Press Release 









Page 

1-1 

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3- 1 

4- 1 

5- 1 

6 - 1 

7- 1 

8 - 1 
9-1 

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TOPOFF2 Cyberex - After Action Report 


TOPOFF2 Cyberex 

Executive Summary 

The national infrastructure of the United States is vulnerable to disruption by physical 
attack because of its interdependent nature and by cyber-attack because of its dependence on 
computer networks. Those who intend to do harm to the United States will seek to exploit 
vulnerabilities using conventional munitions, weapons of mass destruction (WMD), and 
cyber-weapons. Over time, such attacks are increasingly likely to be delivered through 
computer networks rather than using conventional munitions alone, as the attnuitiveness of 
cyber-attacks and the skill of U.S. adversaries in employing them evolve. Cyber-attacks will 
provide both state and non-state adversaries with new options for action against the United 
States beyond mere words. 

TOPOFF2 is the second Congressionally mandated, counter-terrorism exercise 
involving senior U.S. government officials, multiple Federal / State / Local agencies, and 
Canadian government agencies. The goals of TOPOFF2 were to improve the nation's 
capacity to manage extreme events; create broader operating frameworks of expert crisis and 
consequence management systems; validate authorities, strategies, plans, policies, 
procedures, and protocols; and build a sustainable, systematic national exercise program to 
support the national strategy for homeland security. While traditional crisis and consequence 
management organizations were the principal foci of TOPOFF2, there exists another element 
of our country’s critical infrastructure that experts consider highly vulnerable to terrorist- 
related attack; the naticmal information infrastructure. 

TOPOFF2 CYBEREX was a functional exercise to examine, in an operational 
context, the integration of inter- and intra-govemmental actions related to a large-scale 
cyber-attack synchronized with a terrorist WMD attack against a major urban area of the 
United States. In the course of these proceedings, players addressed those actions needed to 
limit the potential damage caused by network compromise and to minimize the impact on 
operations resulting from the loss of these resources. While exploring the vast complexities 
of these individual and inter-related actions, this exercise provided an opportunity for 


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TOPOFF2 Cyberex - After Action Report 


decision-makers and staffs to identify, discuss, and resolve critical issues associated with a 
cyber-attack and other significant disruptions to their network infrastructures. During these 
activities players explored potential vulnerabilities and anticipated responses to determine if 
and what changes might be necessary to existing cyber-security programs and organized 
responses. Approximately 125 people participated in the exercise on the 6^** and 7''^ o^!ay, 


ter in Came. 


2003. The exercise was held at the Washington State Emergency Operations 
Murray, Washington. 


Lessons Learned; 


Participants saw value in a regionally coordinated cyber-security in timely 

exchange information and collective response. The developmenbofthis regional approach 
between State and Local government agencies thatjgarticipated in TOPOFF 2 will continue 
post exercise. 




The exercise highlighted a ne^^^^amine t^^cyber-response plans and procedures 
correspond to changes of the color-codea Nat ional threat condition promulgated by the 
Department of Homeland Security (DHS). From a cyber-perspective, what proactive steps 
should be taken when the threat condition escalates from yellow to orange and then to red? 
The players examined these and other similar questions. 


There are no formally established processes, similar to those in place for a physical 
attack or natural disaster, that address coordination between the federal government and its 
state and local counterparts in the event of a cyber-attack 

The ability to maintain information technology (IT) infrastructure is predicated on the 
fact that individuals will be able to get to their workspace. In those instances where this is 
not true, government agencies responsible for IT infrastructure should examine how they 
would perform mission-critical functions such as backups and systems maintenance from 
alternate locations. 


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TOPOFF2 Cyberex - After Action Report 


During the pre-exercise period, federal government agencies responsible for 
infrastructure protection were not yet completely evolved due to the stand-up of the new 
Department of Homeland Security. The federal government should develop an integrated 
cyber-response plan that addresses crisis support to both state and local governments. There 
is a need for a single point of direct contact between the federal government and State and 
Local 20 vemments for dissemination of information related to cvber-attacks. 



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TOPOFF2 Cyberex - After Action Report 

Section Two: 

TASKING 


Introduction 

The Institute for Security Technology Studies at Dartmouth College (ISTS) is a 
federally funded Institute which was founded in the FY 2000 appropriation as a national 
center for counterterrorism and cyber-security R&D. Our mission is to work to secure 
computer networks against attack, enhance Law Enforcement investigative capabilities in 
cyber-crimes, and serve as a center for counterterrorism technology research, development, 
testing, and evaluation. To accomplish this goal we have over 70 researchers at Dartmouth 
College and employ 20 researchers from other institutes working on research projects related 
to this mission. 

Funding for the ISTS at Dartmouth College was supported under Award number 
2000-DT-CX-K001 (S-2) from the Office of Justice Programs, National Institute of Justice, 
Department of Justice. 

The Office of Domestic Preparedness (ODP) had decided after TOPOFF 2000 that 
TOPOFF II should include a cyber-component. Representatives from ODP met with the 
Director of the ISTS at Dartmouth College early in 2002 and the two organizations agreed 
that the ISTS should take a lead role in preparation and conduct of a cyber-exercise for 
TOPOFF II. Not only does this task align with the mission of the ISTS, but this relationship 
ensured that the ISTS could provide funding necessary to conduct the cyber-exercise for 
TOPOFF II at no cost to ODP. a necessary condition for completion of the project on 
schedule. 


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TOPOFF2 Cyberex - After Action Report 

Section Three 

Stakeholders 


Principal Stakeholders 

TOPOFF2 CYBEREX players were primarily those Federal, State, County, City, private 
sector, and personnel from the Government of Canada who have active roles in the daily 
operations, management, and security of their information networks, systems, or infrastructure 
within their organizations. These participants would most likely play key roles in responding to 
or managing the consequences of a significant regional cyber-di^ptiOTspr attack. The principal 
stakeholders in the exercise were; 

• IT organizations and Top Officials 

> Washington State 

> King County 

> City of Seattle 

Supporting these players were representatives from the following organizations: 

> A commercial telecom provider and local Internet Service Provider (ISP) 

>• Federal computer incident response agencies 
^ Federal law enforcement agencies 

Organization and Roles 

The following is a summary of the organizations involved in the exercise. 



• Five Network Operation Centers (NOCs) participated in this exercise: 

> City of Seattle 

> King County 

> Washington State Department of Information Services (DIS) 

> Washington State Department of Transportation (DOT) 


3-1 



TOPOFF2 Cyberex - After Action Report 

> Washington State Emergency Management Department (EMD) 

Each exercise NOC was composed of individuals from within the organization who are 
assigned to these NOCs on a routine basis. These groups responded to and managed 
consequences presented in the exercise. Because of the restricted time available during the 
exercise, not all elements of an organization’s response were addressed. Unresolved feues 
necessary to keep a NOC’s actions and deliberations flowing were resolved by a group’ s^^ 
facilitator or the Control Team and brought forward during the final plenary seSi^^ The 
general responsibilities of the NOCs included: 

> Assessing network status. IIL 

> Exploring the impact of differing proactive response^ro^i^. 

> Responding to network disruptions. 

>■ Providing periodic summaries to Top Officials (TOPOFFs). 

> Developing recommendations for TOPOFFs. 

> Sharing information with oth» NOCs. 

> Sharing resources with other NOC’s. 

> Responding to mock media inquiries. 

• A group of Top Officials from Federal, State, County, and City government organizations 
participated in TOPOFF2 CYBEREX. In addition to observing exercise activity and assessing 
their ability to work as a team, these officials acted as an executive body to address and resolve 
cyber-security issues challenging the NOCs. These senior executives were incorporated into the 
TOPOFF Coordination and Communication Group (TCCG). The function of the TCCG was to 
provide a forum for senior executives to: 


> Gain and maintain situational awareness of emerging events, develop strategic 
courses of action to conduct a concurrent and integrated response, and direct 
appropriate actions. 

>• Mitigate consequences of enterprise network disruption or loss. 

> Address and resolve the allocation of limited resources among competing 
demands. 


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TOPOFF2 Cyberex - After Action Report 

> Collect, analyze, formulate, and disseminate information to stakeholders in 
and outside the state, including the media. 

> Develop recommendations for political leadership (chief executive) approval 
or action. 

> Respond to inquiries from senior executives of the Federal government. 


Accordingly, to work effectively in an inter-governmental environment, the Top Officials 
from each organization assigned to the TCCG had experience, authority, and access to the 
organization’s political leadership. Chief information / chief technology officers (CIO / CTO) 
and/or members of their immediate staffs filled these positions during the exercise. Top 
Officials came from the following organizations: 




State of Washington CIO / Director of Washington State DIS 
State DOT (Information Technology Section) 

State EMD (Telecommunications Slection / Director’s Office) and National 
Guard 

Office of the Governor 

King County (Information and Telecommunications Services Division / 
Office of Information Resource Management) 

City of Seattle (Department of Information Technology) 

University of Washington (University Computing Services) 

Top Officials played by the Control Team: 

Governor 

0 County Executive 

01 Mayor 

o I ^Department of Homeland Security (DHS) 


Ano^r group, acting in support of the TCCG, consisted of regional government and 
corporate representatives who would have a logical role to play given the scenarios. Unlike the 
NOCs and the TCCG, the Support Pod had no direct “play” in TOPOFF2 CYBEREX. Rather, 
their role was to provide information to, and respond to resource requests from, the principal 
players. Representatives of support organizations had an in-depth understanding of the 


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TOPOFF2 Cyberex - After Action Report 


technologies, capabilities, and processes that their organization would provide the principal 
players, and the methodologies to avail these resources. 


The following diagram depicts the overall organization of TOPOFF2 CYBEREX. 



TOPOFF2 requiremeti^ stated that: “This series of exercise components will also 
improve ‘crisis resistance’ through opportunities to measure plans, policies, and procedures 
required to provide an effective response to a weapons of mass destruction (WMD) terrorist 
incident.” This type of incident would be more complex and significantly challenge the 
capabilities of organizations assigned the responsibility of providing a first response if 
government-related information networks were simultaneously and maliciously disrupted due to 
a large-scale cyber-attack. Accordingly, within the context of a TOPOFF2-like WMD event, the 
players gave due consideration to the following issues and objectives during the development of 
the CYBEREX: 


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TOPOFF2 Cyberex - After Action Report 


> The effectiveness of the various cyber-security plans, policies and procedures 
of the City, County, Stale, and Federal levels to adequately address issues and 
support the response for a large-scale cyber-attack on government-related 
information networks. 

> The ability of participating NOCs to organizationally integrate and effectively 
conduct or manage a sustained response to a cyber-attack. 

> The planned flow of communications and information in an operational 
context. 

> The decision and coordination processes in a range of potential consequences. 

Within these overarching set of objectives, each of the principal stakehold«^ had their 
own objectives for this exerci.se. These included: 

>■ DIS - Determine that the Washington State Computer Incident Response 
Center (WACIRC) procedures -- including incident reporting, response, 
escalation, communications, containment, etc. --’were sufficient to effectively 
mitigate the effects of cyber-attacks. 

> City of Seattle & King County - Develop policies and procedures relating to 
large-scale cyber-attacks, including federal notification and response. 

> City of Seattle & King County - Determine the effectiveness of the draft 
policies and procedures along with federal notification procedures. 

Throughout the development of the exercise, these objectives guided the design and 
methodologies used to achieve the stakeholders expectations. A flexible design structure was 
used for the development of this exercise, thus allowing for the incorporation of new objectives 
should they arise. 

It became apparent during the design of the game that the principal stakeholders realized 
that there might be significant value in developing a regional approach to a response to a major 
cyber-attack. The stakeholders held several meetings to address this regional approach to the 
problem. One outcome of these discussions was the proposal for a regional information sharing 
system to be used by the stakeholders to report significant anomalies occurring on each 
organization’s networks. This prototype system, entitled the Regional Information and 
Intelligence Gathering (RUG) was exercised in the two-day event. Additional refinement on this 
initiative was planned after the exercise based on how the RIIG was used during the event. 


3-5 



TOPOFF2 Cyberex - After Action Report 


Additionally, this exercise was designed so that principal stakeholders may develop 
strategies and planning frameworks to: 

> Coordinate inter-governmental responses and consequence management to 
cyber-attacks. 

>- Maintain continuity of operations within participating organizations. 

> Develop alternatives and recommendations to senior or executive decision- 
makers in responding to potential cyber-crisis events. 

>■ Sustain confidence in government information networks during a cyber-attack 
and, if neces,sary, regain public confidence. 

Each participating organization developed its own self-evaluation criteria for the 
exercise. Inclusion of these criteria and the results of their assessment go beyond the scope of 
this report. Here we address information and resources sharing between organizations. 

The following is a summary of the organizatiiMis participating in TOPOFF2 CYBEREX: 
King County • Department of Transportation 

• Department of Executive Services • Police Department 

. Department of Natural Resources and . Seattle Center 

Parks • Seattle City Light 

• Department of Public Health • Seattle Public Utilities 

. Department of Transportation 

. Information and Telecommunications 
Services Division 

• Office of Emergency Management 

• Prosecuting Attorney's Office 
. Sheriff’s Office 

City of Seattle 

• Department of Information 
Technology 


3-6 



Washington State 
. DIS 
. DOT 
. EMD 

• Office of the Governor 


For Off i c i al Us e On l y 

TOPOFF2 CYBEREX - After Action Report 

Other Participants 


Canada 


Office of Critical Infrastructure and 
Emergency Preparedness 
Province of British Columbia Ministry 
of Management Services 
Province of Ontario Information 
Protection Center 




Boeing Corporation 
Federal Bureau of Investigation - 
Seattle office 
CERT at Carnegie Melon 

V. ^ 

National Communication Syswfij 
Microsoft Corporatic 
Qwest Corporation 
United States DHS 
United States Department of State 
United States Secret Service - Seattle 
Office 

United States Attorney 
University of Washington 



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TOPOFF2 CYBEREX - After Action Report 


Section Four 

Seminars 


As part of the exercise development and learning process for the stakeholders, wefteld 
two seminars in the Seattle area at the Criminal Justice Training Center. Each ^as attended 
by about 1 25 people from the stakeholder community including State of Washington, King 
County, and City of Seattle’s government agencies. Representatives from the Port of Seattle. 
Boeing, Microsoft and the University of Washington also attended. The semiiiflrs were held 
at no cost to the participants. In general, presenters donated lheir''ijine^^ travel expense. 

V - 

Seminar I ; Notification Policies Seminar - to review areas cS^E^ftonsibilities of federal 




agencies, reporting thresholds, trigger points to-®tcess resourceSi,and escalation 
procedures. 




' . ^ 


Held 6 February, 2003, 
Moderator; 


(C))(6) 


lormer Director of the Department of Defense 


Cyber Crime Center. 
Presenters 


o 

o 

1 ° 

o 

O! 

O 

o 

o 


(bK6) 




(bK6) 



Qwest 

=[anj^ 


- OCIPEP of Canada 


- ISTS-Dartmouth College on the recent Slammer 


Worm 


4 -] 





For Off i c i al Us e On l y 

TOPOFF2 CYBEREX - After Action Report 


Seminar 2: Threat Assessment Seminar - What are the threats, what are the tools we 
have to defend against them, how do we conduct a cost benefit analysis to determine 
which tools to invest in?. 


o Held: 1 1 March 2003 
o Moderator: Dr.[[M6^ 
o Presenters: 
o Dr 


^ CIA Senior Scientist - Info Qps Center 


(b)(6) 


- National Security Counci!, Office of 


Cyberspace Security 


o 

o 

o 

o 

o 



(b)(6) 


(b)(6) 


(b)(6) 


- UnivCTsiiy of Washington 


- City of Seattle CISO and founder of Agora 
-Deftwe.in Depth 




V. 


4-2 




TOPOFF2 CYBEREX - After Action Report 


Section Five 

Simulation 


A 


As the CYBEREX portion of TOPOFF2 was conducted on a not-to-inierfere 
with the principal exercise, the network operation centers (NOCs) of participatjog 
organizations employed a simulated network, developed by the Institute for SeikiTil^ 
Technology Studies (ISTS) at Dartmouth College as a primary source,oj-exerci(i|p-r 
stimuli. y. 


- y 




This simulated network replicated the functional elem^t:»^regidfiftLwfde area 
networks, inter-governmental networks, and access to the pubficTnirt'het. Exercise designers 
worked with network managers of participating q^aflizations to develop a plausible 

emulation of the organizations' networks, wt^ ensuing that the simulation did not reveal 

• 

critical vulnerabilities or disclose exact security *JTi^suVeff. Participants had final approval on 
the network simulation used by their it^anization dui^Bg operational exercise activity. The 
below diagram depicts a simulated network used by one of the stakeholders: 




For Off i c i al Us e On l y 

TOPOFF2 CYBEREX - After Action Report 
Employing a Master Scenario Event Listing (MESL) developed before the exercise 
with the assistance of stakeholder Trusted Agents, simulation controllers were able to 
generate disruptions to simulated network hardware, such as workstations, routers, firewalls, 
servers, and to the connectivity “pipes” connecting them. These controlled disruptions were 
based on actions of the attacking agents and included malicious events and normal 
disruptions. The effects of these disruptions were revealed to the players on a Web-based 
display application that highlighted the location of the disruption and often its severity. 
Remediation of these problems was made through player interaction with members of the 
network control team. Details of the MSEL are included as an appendix to this report. 


In addition to stimuli being provided by the network simulation, participants received 
injects through an exercise communication system developed for the CYBEREX. From a 
single computer workstation, participants could send and receive e-mail and replicate the use 

Before interactive play of the exercise bega^^perators of the network status display 
consoles were indoctrinated on its us^^^^^ng of tffls network was also provided to 
participants as part of the opening orientation sesaon. 





V 


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TOPOFF2 CYBEREX - After Action Report 


Section Six 

Exercise Design 


Concept of Exercise Activity 

TOPOFF2 CYBEREX was a facilitated, computer assisted, one and one-half day, 
immersive, scenario-supported, and network-aided interactive exercise where executives and 
staffs of governmental information technology (IT) organizations explored the challenges of 
managing disruptions to critical computer networks caused by a terrorist cyber-attack. 
Participant activity was centered on three vignettes, each associated with different aspects of the 
complex cyber-security problem. The successive vignettes represented escalating levels of 
attack and stress for the players. The attacks simulated during the exercise were designed to 
expose players to a series of exploits which have all been seen in the wild, but which they 
themselves may never have seen before. The following digram depicts the construct and flow 
of these vignettes: 



6-1 




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TOPOFF2 CYBEREX - After Action Report 
The following is a brief description of each vignette. 

• Vignette One: Sporadic attacks that affect the State, County, and City network 
operations. These attacks were not to occur simultaneously, and appeared somewhat 
disjointed. The intensity of the attacks represented an above-normal level of 
malicious activity. 

• Vignette Two: Coordinated attacks of longer duration that reflected multiple attack 
methodologies. Attack intensity corresponded to the high-end of normal malicious 
activity and was intended to cause minor to moderate disruption of government 
information networks. 

• Vignette Three: Attack coincident with the weapons of noass destruction (WMD) 
event that incorporated the gamut of public-knowledge attack methods. This 
compound attack was intended to be a "force multiplier” of the WMD event and was 
directed at specific networked entities with crisis or consequence management roles. 

A Hot Wash-up concluded the interactive portion of this exercise. Each group presented 
the significant and unresolved planning and management concerns, critical issues, and 
recommendations identified in each session. 

First and foremost: This exercise was not a test. Rather, it was an opportunity for 
participating organizations and individuals to stress their plans, policies or procedures, improve 
coordination and confidence, augment skills, refine roles and responsibilities, reveal weaknesses 
and resource gaps, and build teamworit. 

Although the incident management and cyber-security plans used by participating 
organizations provided a foundation for players’ actions, these actions and decisions were not 
constrained by these plans or other current, real-world plans and management concepts. 

Exercise Technique 

The overall technique employed for this exercise was based on an input ^ action ^ 
output paradigm. Using information provided by a scenario, injects, or network status displays. 


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For Off i c i al Us e On l y 

TOPOFF2 CYBEREX - After Action Report 
participants responded to issues related to a vignette. Facilitators assigned to each group 
assisted the participants through the exercise process and discussions. The following depicts the 
general flow of this interactive technique: 


Exercise Technique 


INPUTS 
Scenario 
Internal Reports 
Media Reports 
Network Data 
Scripted Injects 
Contingency Plan 
Others 




% 


PROCESS 
Assess Situation 
Revalidate Assumptions 
Identity Implications 
Develop Courses of Action 
Review Resources 
Make Recommendation 
Take Actions 





% 


OUTPUTS 
Recommendations 
Network Actions 
Internal Reports 
External Reports 



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TOPOFF2 CYBEREX - After Action Report 
The principal organizational structure for each stakeholder was a Network Operations 
Center (NOC). The diagram below provides a notional layout of an organization’s NOC: 


Notional NOC Layout 




Communication 

Operator 

Network 

System 

Administrator 

Control staff: 


< Facilitator 

NOC 1 

* Recorder 

Leader 1 

* Observers 1 



Incident Response / 
Consequence Management 
Group 


15 © 


:3I 


\ 


Each NOC had three primary entities: 




V 


NetworPSv stems Administrator (NSA) 

\ / 

Incident'Response / Consequence Management Group (IR / CMG) 
Commumcations Operator 

The,f«Sn()wim; disiussitMi details the roles and responsibilities of members of the NOC. 

A. ' 1 ^ 

• Network System Administrator (NSA): 

Using data and information provided from a computer display, the NSA was responsible 
for monitoring the network, and identifying, documenting, and recommending solutions to 
problems discovered. Additionally, the NSA took actions, within his / her authority, to respond 



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to the network situation. The NSA also performed network systems troubleshooting to isolate 
and diagnose system problems. This individual was experienced with the organization’s 
network topology and NSA procedures. Additionally, the NSA possessed an understanding of 
the underlying technology behind the hardware operating the network and the principal software 
applications residing on the network. The NSA had the ability to order equipment to be taken 
off-line, rebooted, and could install filters and block ports. 

• Incident Re.spon.se / Consequence Management Group (IR/ CMG): 

The function of the six (6) individuals composing the IR / CMG was to ntspond to a 
significant network disruption or security incident using the organization’s plans, policies, and 
procedures in order to contain, investigate, recover from, and report the incident or disruption. 
The City of Seattle, King County, and Washington State Department of Information Services 
(DIS) NOCs each had a six-member IR / CMG. The NOCs for the Washington State 
Department of Transportation (DOT) and Emergency Management Department (EMD) had a 
smaller group. 

The activities of this group included, but were not limited to: analysis of the situation to 
determine potential consequences; employment of an organization’s mitigative or defensive 
strategies and resources; documentation of the incident; forensic evidence collection; and 
investigation. The utility of the IR / CMG was similar to each participating organization's 
incident response team (IRT) or computer emergency response team. 

Most IRT’s have both an investigative and a problem-solving component. These 
functionalities resided in the NOC IR / CMG. This group included management personnel who 
understand the organization’s security, emergency, legal, or network policies, and has the 
authority to act: technical personnel with the knowledge and expertise to diagnose and resolve 
problems; security personnel able to track security issues and perform in-stride and post-mortem 
analysis; or communications personnel able to keep the appropriate individuals and other 
organizations informed as to the status of the problem and, if necessary, assist in developing 


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crisis response strategies. One of the six members of this group acted as the leader for the 
organization’s NOC. 


• Commumcation.s Operator 

The function of the communications operator was to monitor external communications 
(e-mail and telephone) for the NOC and relay information coming from these sources to the 


NOC. 


Exercise Control 


i 







An exercise Control Team oversaw the execution of this exercise and was composed of 

\ V V I 

personnel familiar with the exercise objectives, process, and constru^^'niisigcdup monitored 

all activities throughout the exercise and adjusted the process'^necessary to keep the 

'’a 

participants oriented toward outcomes that suim orttW ^rcise objectives. The Control Team had 
overall responsibility for directing the exercisftprocess, administration, and plenary sessions. 


Facilitators and data collectors appointed to eacir^dwe!?members of this group. The Control 
Team also tracked and evaluated criticaLoutcomes^^the conclusion of each session. This 



group assessed the activity of each podland,Jfliecessary, provided supplemental information 


that clarified the scenario. 





The exercise technical control^taff resided with the Control Team. This staff generated 
scenario injects depicting the''^atus of an organization’s network for viewing on each pod’s 
network sta^^fesplay and injected scenario elements depicting challenges that consequence 
managers would live to address. 


The exercise Design Team indoctrinated members of the Control Team, stakeholder 
facilitators, NSAs, and communicators prior to the conduct of the exercise. Included in this 
training were: 


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> The exercise process, including the organizational structure, the flow of 
activity, and the expectations at the end of each session. A walk-through 
of the participant handbook and facilitator guide also occurred. 

> Exercise pre-play to demonstrate the expected levels of discussion and 
required session products. 

> A tour of the exercise site to understand the flow of the interactive 
process and to prepare the pods for exercise activity. 

>• An indoctrination and practice period using the simulated network 
(NETSIM) display console and communication laptops. 

This training provided members of this team with the requisite' infoimatib 
to effectively perform their roles. 





. V 


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Section Seven 

Game Play 


In addition to responding to the stimuli provided by the simulated network (NETSIM) 
and other injects, we tasked participants to prepare responses to questions addressing key 
issues associated with the theme of each vignette. During the plenary sessions held at the 
conclusion of each vignette, a member of each pod discussed the organization’s responses to 
these questions. The following summarizes this activity and the, players’ discussions. 


Vignette One: Normal Day At the Office 




The theme of this vignette was an “above narmal’’ level of disruptions to the 
information networks of each organization. Using information and data provided through 
network status displays or injects provided by the Control Team, each pod responded to these 
stimuli by employing their incident plans, policies, and procedures. In addition to exercising 
these tools, during this session participants were tasked to review their incident response plan 
assumptions, review the internal and external communication flows of their Network 
Operations Centers (NOCs), and discuss relevant cyber-security issues. Following this, they 
identified and prioritized thec«‘ganizational implications of prolonged periods of “above- 
normal" network disruptions and how these might influence planned processes, courses of 
action, and resource requirements detailed in their response plans. 

Questions for Plenum 

• What does the Department of Homeland Security (DHS) “Condition Yellow” 
mean to your organization, in particular to its network security? 


7-1 



City of Seattle : 


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Practice information technology (IT) callout and alerting plan / verify numbers. 

Consider alternative work schedules of operational staff. If situation escalates, plan 
to maximize staffing & response capabilities. 

Increase frequency of review of firewall logs and monitoring of other intmsk 
detection systems. 

Pass advisory to department emergency contacts. 

Introduce measures outlined in BLUE advisory. 

Consider canceling or rearranging vacations and other time off to 
capability. 

Conduct security check on all critical systems. 

Be aware of physical access to restricted areas, e.g., coifeun^tions closet, server 
room. 'j/ 

Consider increasing frequency of backups.ieiisure offsite stoiage. 

Review network segmentation plans. 






Ensure employees (especially those with fifeld / remote responsibilities) remain 
vigilant for spotting suspiciou^ctivities anSbehavior and are prepared to report it 


immediately to Seattle Police Deptttment (SPD). 


King County ; 



\ 

V 


Condition Yellow is'ti^miiial^felevated level of network security post-Sept. 1 1). 

King County has developed an incident management plan detailing roles and 
responsibilities in the eyent of various disrupted services. 

, ^ A 

Washington State Department of Information Services (PIS) : 




I - “rviic i:.: ^ 


DHS Condition Yellow does not invoke any additional security activity at DIS. This 
situ^on is considered a normal activity. 

At Condition Yellow. DIS is at heightened awareness for physical issues — such as 
building security. 



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Washin2ton State Department of Transportation (DOT) ; 


Send notification of increased alert level to employees for increased awareness. 
Increase frequency of system log scans. 

Contact response team members to coordinate a plan of action. 


Washln2ton State Emergency Manaeement Department (EMD) ; 


> Our organization is always at its highest level of network securjt 

> Block all executable files on a daily basis. 

> Daily - run McAfee, updating DAT files. 

> Daily - run IP Sentry to monitor network. 

> Daily - run full back-up (13-14 hours). 

> Subscribe to various LISTSERV - Multi- State (MS), SANS, Federal Computer 
Incident Response Center (FedCIRC). 




V 

u rity. \ 



How is a “normal day'' determined in yourOTganization? 


City of Seattle ; 



Power is generatedti^ater flows, Ba^uys get arrested, fires are extinguished, lives 


saved, people play in pari^ 

National threat level is-stable.' 

\ 

Minotproblems as indicated by number of Help Desk tickets. 


External ^ngs - Internet Team notified of failures. 
' \ 

Main systems up - no major outages. 

^ KmgLCountv ; 


> A "Normal Day" is assumed until indications are otherwise. 

> An extraordinary day looks like: 

> Global outage. 

>• Global e-mail server attack. 

> Global phone service disruption. 


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> Mainframe outage. 

Washington State DIS : 


> Monitor network on a regular basis. 

> Experience on-going scans from the Internet. 

> Develop and implement on-going .security changes. 

> Hold internal security meetings. 

> Continue to monitor logging information. 

Washington State DOT : 


..V 







Equipment failures, network configuration issues, trainmg'and u^i^es, SPAM, 
questions from customers about viruses, testing and ajjplicatitMi of system patches, 
responses to changing architecture software. 

More exciting than a normal day. 



> System monitors indicate problems, nrtification of threats are received, and incoming 
messages are received that contain unkno^ cotSenUr' 


Washington State EMD ; 


> All network services are live and accessible. 

> Network latencies to these services do not exceed 300 ms. 

> Electrical services are functioning on commercial power. 

What do you consider your organization’s most significant cyber vulnerabilities? 
City of Seattle : 


Access levels to applications and data are not audited on a regular basis. 

Internal 802. 1 1 Wireless and other remote access e.g., CDPD, Digital Subscriber Line 
(DSL), Inter-Governmental Network (IGN), Integrated Services Digital Network 
(ISDN). 


> Employees; background checks, training, discovering wayward behavior. 

> Gaps in communication protocols with other agencies / partners / vendors. 

> Lack of policy and staff training for dealing with suspicious e-mails. 


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Establish consequence management team (IT managers). 

Viruses externally introduced to the environment. 

Trust issues with sharing passwords and common logins. 

Lack of network segmentation and redundancy. 

Patch levels on old systems - legacy applications cause them to break. 

External virtual private network (VPN) Access - lack of audit ability for firewall aad 


virus protection. 
King County : 




i V 

> Limited County-wide standard for patch and configuratido-maiiagemen& 

> Budget constraints prohibit us from implementing int^rdeoartmenia sgcu fitv 
standards. 




xx: 

guag^'^' ' 



Very limited internal firewalls -- perimeter security only., 

Some external-facing resources on internaffl^ork segments (available to public). 
Issues: 


No inventory of structured query language (^L) database and IIS servers within the 
County network. 


Policy guidance for investigative qu€ 

Governing authority by ordinance to set and enforce security policy (cyber world). 


ifiom legal entities. 


Washington State PIS 




V 


> Non-disclosure agreement (NDA) would be required before we can answer this 
question. 

> Standard e-mail and Web portal traffic, security awareness. 

* In a confederation of government organizations, we are subject to the "weakest link" 
syndrome. 


Washington State DOT : 


> Lack of backup data "hot” site should the primary become unavailable. 

> Incoming e-mail / viruses from attachments. 

> Lack of monitoring tools. 


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> Social engineering. 

> Constantly changing architecture of hardware and software. 


Washin£ton State EMD : 


> Our biggest vulnerability at this point is our single connection to the Internet through 
DIS. We have redundancy. 

> Lack of internal firewall / intrusion detection systems (IDS) 

> Currently, only e-mail is authorized to be transmitted on the State Governmental 
Network (SGN). Authorization and setup of VPNs is time consuming and cannot be 
done solely by EMD, 

> Internal customers storing files with viruses on their computers. Internal firewalls on 
each computer are needed and will be installed in the immediate future. 

Solutions to overcome these challenges: 

> Additional funding is being .sought to install two new Tls for Internet connectivity. 
One T1 should be to a tier one service jM’ovider such as Sprint or Uunet. The second 
T1 should be satellite providing Internet connectivity. All of our circuits will be on 
physically diverse routes terminating in geographically diverse regions. 

> We have purchased and will be installing firewall and IDS systems as well as routers 
specifically for doing our perimeter m outer layer of cyber-security. 

What single events might cause your Incident Response Team (IRT) to 
activate? 

> A local area network (LAN) outage causing di,sruption to more than 10% of the 
network services. 

> A wide area network (WAN) outage. 

> Detection of a virus / worm outbreak. 

What cumulative events might cause your IRT to activate? 

> Network probe accompanies by an intrusion or intrusion attempt 


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Vignette Two: Coordinated Attacks 


The theme of the second vignette was a low-level coordinated cyber-attack against 
stakeholder organizations. Players addressed issues or actions necessary to respond to these 
attacks in a combined manner and to resume network operations. After recognizing 
indications of abnormal events, participants analyzed the problem and responded 
establish the operations of their networks. Working in their respective NOCs, 
initially assessed the situation, implemented their response plans, and determin^ wliat^ 
additional actions, coordination, and/or resources were necessary. As the^ifeiatio.i^re^ted 

h^e outstripped 


L 

lizing 
ed to re- 
p^art^)ants 


i,^^ay h^( 

V... 1 


may become greater than what was anticipated by each organization, it 

\ V T 

available internal resources. This session provided the opportunity for participants to 
discover the need to revise policies, procedures, resource allo^ioii,'^^rid/or communication 
flows to account for vulnerabilities identified byjj^^ignette that were not addressed by the 


,ed by tfa^^ignette thti 


organizations’ plans. 
Questions for Plenum 


What does the DHS '^Condition Orange" mean to your organization, in particular to 
its network security? 




City of Seattle ; 


Pass'al&t on to departrpent emergency contacts. 


> Continue or introduce measures listed in YELLOW advisory. 

V Via call-out lists', contact all essential personnel regarding their recall availability. 

% 

> ‘’'^'Exercise test alert of all 24 x 7 on call staff between departments and coordinate 

?c^dules for critical staff across departments. 

> TesCcommunications; e-mail. 800 MHz radio, carrier pigeon. 

> Suspend public tours of infrastructure. 

> Increase staffing and backup for system monitoring. 

> Change passwords and physical access codes. 

> Verify availability of key vendors. 


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King County ; 

> Notify staff and review policies and procedures on how to respond to an attack that 
occurs during DHS Condition Orange. Condition Orange would command different 
actions from those previously executed in Condition Yellow. 

> Communicate with other agencies to coordinate policies and procedures that are 
implemented at various DHS alert levels. 

Washington State PIS ; 


Increased security in all buildings. 


\ 




Broadcast message to all DIS personnel about heightei^’Stat^ 

Be more vigilant, higher awareness among receptionists to asK for ID. 

Facilities staff would ensure backup gen erators , etc. are ready; to go. 

Network Security: same as "usual dayjj^ctivi^s. with reinforcement among staff to 
be aware of their surroundings and peopleJ^n,die.ar^., 


> Look for anomalies in network activity. ^ 

Washington State DOT ; 

> Limit physical access to computer facilities. 

> Deny access to outside vendors. 

> All non-DOT IT personnel will be escorted at all times. 

> Increased attention to system monitoring. 

Washington State EMD : 

> How does this differ from a "normal level" of security? It does not. 

> How does this differ from DHS "Condition Yellow"? It does not. 

What is the role of your IT organization in the emergency management 
organization? 


City of Seattle ; 


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> F*rovide logistical and communications systems support,. 

> Monitor IT infrastructure status 

> Respond to IT related problems 

> Restore service, e.g. radio, telephone, computer network, e-mail, messaging. File and 
print services, dispatch, and critical databases. 

Gaps: 

> Focus on City IT resources as an asset, implement policies and practice!^ safeguai^- 
protect, facilitate recovery and assure continuity of business. 

King County : 

\ 

> Provide support to King County Emergency Organization. V 

> Clarify access procedures regarding King County "meerme"^room locations. 

> Clarify access procedures for Comcast POPs. 

> Clarify physical access requirements h 
DHS conditions. 


Washington State PIS : 





■fing and networking areas relative to 


DIS has a practice of sharing security incident information with EMD through the 
Washington State Computer Incident Response Center (WACIRC) 

DIS general rule is to: 

Be a focal point for sharing security information with regional partners. 

To conduct incident notification and response coordination. 

To carry out monitoring and mitigation for SGN and IGN systems, and regional 
partners (City of Seattle, King County EMD, and DOT). 

DIS Computer Incident Response Team (DISCIRT) was formed in 2002 as an IT 
organization internal to DIS. DISCIRT is the starting point for statewide incident 
response that includes EMD. 

DIS and EMD have joined the multi-state Information Sharing and Analysis Center 
(ISAC) started in New York. EMD represents the physical side, DIS represents the 
cyber side. 


Washington State DOT : 


> External - communication with WACIRC via e-mail, fax, pager, phone, and cell. 


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> Internal - As a support organization for our internal Emergency Operations Center 
(EOC). We specifically support EOC e-mail and hardware (printers, PCs, faxes, 
etc.)- 


Washington State EMD ; 

> To help coordinate resources when the resources of the local jurisdictions are 
overwhelmed. To act as liaison between the Local, State, and Federal r^ponse 
agencies. 

What are your recommendations for a regional response / defense to a wide^ale 
cyber-attack? 


City of Seattle ; 


Develop relationships and protocols related to vertical lines'of business; public 
safety, utilities, human services, etc. 

Organize an inter-agency “Crisis Response” Team to immediately activate and begin 
analysis and classification of the agent of attack and coordinate respon.se in a real 
time manner. 

Support LISTSERV for WACIRC Level 2 & 3 problems. 

\ 

Activate and communicate with >yAClRC, once activated by DIS for Level 
problem. 




King County : 


> Establishment of inter-agency communication points of contact list. 

> Create inter-agency roles and responsibilities plan. 

> Analyze data generated from a host-based and network-based IDS inside King 
County Wide Area Network (KCWAN) perimeter. 


Washington State DIS : 


> Early information sharing about potential security incidents and status of incidents in 
process. 

>• Central coordination through regional and statewide LISTSERVs. Out-of-band, non- 
dependent notification system is in place for WACIRC. All regional partners should 
consider similar. 


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> F*rocess for states, cities, and counties escalating to federal and international agencies 
is not yet solidified. 



7-11 



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Washington State DOT ; 


Obtain management approval for dropping outside internet connectivity. 
Increase system monitoring effort. 

Increased reliance on out-of-band communications. 


Have Public information Officer (PIO) send alerts via television stations 
DOT camera feeds. 


Washington State EMD : 


IS carrying^ 


In this case, the best defense is a good offense. Having o^be 
in place. 


'a; 




cuntyiSfst practices 
N 


ng (Wbei^d^cu 

\ . ) 

Having redundant paths to your services. " 

Early detection determination, and warning with IDS and firewall protection. 
Coordinating response efforts with stakeholders and vendors involved. 


• What is your organization's responsibility to entities outside your jurisdiction with 
regard to a wide-scale cyber-attack? 

City of Seattle ; 


Post WACIRC Level 2 and 3 incidents to LISTSERV. 

Contact DIS Help Desk for Level 1 incidents. 

Contact King County operations and management. 

Engage Internet Service Providers (ISPs) in incident response. 

Gaps requiring clarification: 

To be determined (TBD): relationship with FedClRC, National Infrastructure 
Protection Center (NIPC), DHS. 

Suburban cities: utility services. 

Business Partners: regional wholesale water and power customers. 

Regulatory Bodies: Environmental Protection Agency (EPA), Department of Energy 
(DOE), Federal Energy Regulatory Commission (FERC), North American Electric 
Reliability Council (NERC), Western Electricity Coordinating Council (WECC). 

Auditors. 


7-12 



King County ; 


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Notification and coordination. 

Mitigation of attack traffic. 

Information sharing relative to temporary or permanent solution. 

Issues: 

King County needs a policy for inventory of externally facing websites and where ^ 
they logically reside within our King County network. This will allow us toj^etter 
mitigate risk. ^ 

King County needs a global security policy relative to DHS (^nditt^||^ 

A 

Review authorities for threat conditions. 


> Cooperation / coordination with Canada. 

Washington State PIS : 

> Federal: 

> Provide for information on suspected ille^^^tivityT 

> Communication and notificatirajab^t incider^'that could have national impact or 
that could be coming from other natmns^ 



City/County: 


V 


Primary responsibilit^jj^mtificati^. 

Cities and counties who navelTOmputing assets in DIS environments. 

Neighboring states: 

Currently, no process for providing information. Responsibility as good Net citizens 
is to notify them that there may be a threat again.st them. 

Canada: 

Currently, no process for providing information. Responsibility as good Net citizens 
is to notify them that there may be a threat against them. 

Example in exercise - requested specific network information from British Columbia 
(BC) to allow us to block the worm coming from the SON directed toward them. We 
also notified them that we had blocked traffic. 



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Washington State DOT ; 


> Develop information exchange with DIS / WACIRC to coordinate response efforts. 

> Notify Public of any impact to any DOT external web sites, traffic cameras, ferry 
schedules, etc., via PIO release. 

> Being a good neighbor and alerting others in "neighborhood." 

Washington State EMD : 


N< 



Our procedure is to notify our local emergency management fecilities of thethr&t 
and have them contact DIS for further information regarding the IGN <x SGN. 




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Vignette Three: WMD Force Multiplier 



The theme of the final vignette was an overwhelming, coordinated cyber-attack 
acting as a “force multiplier” for a combined terrorist WMD attack. Issues and actions 
necessary to re-establish or maintain network operations to permit crisis and consequ^e 
management were addressed by the NOCs. In a process similar to the previous sessions, 
participants received indications of the events leading to significant disruptionsra|^tical 
networks. Participants then assessed the situation and took necessary actions toW-establish 
these networks to enable necessary response and governmental oper^ion^fejjcpntinue. 

Questions for Plenum 

• What does the DHS ^‘Condition Red" mean to your organization, in particular to its 
network security? \ 

City of Seattle ; 


Assumes Orange readiness in 




ap^s.. 


Stop all IT changes. 

Mayor declares emergency, activates EOC. 

Take specified acticMis geared to whether Seattle assessed as a target. 
Deploy a 24x7 NOC. 

IT infrastructure staff scheduled 24x7 for EOC. 

Confirm call-out information and notify all IT staff. 

Notify ail IT customers of potential emergency disruption of services. 


King County : 


Obtain intelligence. 

Obtain direction from King County High Level Officials. 
Establish POA consistent with King County plans and Policies. 
Posture and respond accordingly. 


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TOPOFF2 CYBEREX - After Action Report 


Washington State PIS : 

> Increased security in all buildings. 

> Broadcast message to all DIS personnel about heightened state. 

> Be extremely vigilant, higher awareness among receptionists to ask for ID. 

> Facilities staff should ensure backup generators, etc. are ready to go. 

> Network staff would be on heightened awareness, with reinforcement aihong 


be aware of their surroundings and people in the area, watch more closely 
anomalies in network activity. \ 

Review logs more carefully and backup systems more freque^tly^^^ L 


Washington State DOT: 






V 

ftiong staff to^^ 

T 


> Notify all employees of change in threat level. X \ 

> Ensure 24-hour access to management team regarding threat level. 

> Poll and brief IT emergency response personnel. 

> Continuous monitoring for IT infrastructure abnormalities. 

> Increase physical security at IT facilities (possible assistance from Law Enforcement 

/ National Guard). _ 

> Ensure operational condition of backup power generators. 

Washington State EMD: 


> Awareness and monitOTing. 

> How does this differ from a "normal level" of network security? No difference, 
r How does this differ from DHS "Condition Orange"? No difference. 

> What extraordinary actions do / might you take under this threat condition? Increase 
physical security to our network hardware. 

If a regional NOC undergoes a “catastrophic” loss, what resources might your 
organization offer to support the NOC’s continuity of operations? 

City of Seattle : 

> Staff. 

> Vendor relationships. 


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> On-call expertise. 

> Diagnostic support. 

> Communications support. 

> Provide alternative sites for hosting of critical Public Info Web pages and Critical 
Response and Recovery Applications. 


King County ; 

> Physical location. 

> Workstations. 

> Network accessibility. 

> Personnel. 

> Voice communications capabilities. 
Washington State PIS ; 



> DIS could act as a conduit to provide possUde networic technical staff assistance. 

> Possibly provide hardware / software network assistance and a facility (management 
decision). 

> Leverage vendors to get priority delivery for equipment and services, and public 
information assistance. 

Washington State DOT ; 

> Use of satellite-based internet connection 

> Use of 800 MHz radio system 

Washington State EMD ; 


> Talking to vendors and making sure that TWP is being followed. 


• If this loss occurred to your organization what resources might you need and how 
would you get them? 

> Satellite Internet connectivity. Purchase dish from a local vendor and activate 
service. 


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• What are your major requirements for a “NOC in a box”? 

> 24-hour switch, liquid crystal display (LCD) / keyboard, video, mouse (KVM) 
switch, 1 dual=processor Win2K=based server not to exceed 4U. 


If your organization’s networks are degrading gracefully, but rapidly, wtmt are 
your priorities for system continuity? 







City of Seattle : 


Systems and Infrastructure required to manage IT resources. ^ 

Ports, segments and servers required for Public information and internal coordination 
of event— e.g., e-mail. 

Utilities: distribute water, provide drainage distribute power, generate /buy / sell 
power, serve critical customers, bill customers (Supervisory Control and Data 
Acquisition (SCADA), wholesale B2B links. Out-dialer, Interactive Voice Response 
(IVR), On-call, geographical information system (CIS) / Asset Management., etc.). 

Public Safety: 800 MHz radio, dispatch, mobile communications, records systems. 

Administration: post payments, pay employees, make purchases, pay vendors. 


King County : 

> Protect critical applications. 

> Communicating with systems and application owners to ensure they implement their 
business continuity plan. 

> Investigate the cause and develop a protection plan. 

> Inform the public of the impact. 

Issues: 

> Policies and procedures do not provide a process to formulate response (e.g., assess, 
define challenges, and develop response options). 

> How to coordinate internal activities? 

> How to coordinate external activities? 


Intelligence behind the decision to escalate to Condition Red — what does it mean to 
us? 


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Washington State PIS : 


> Keep Access Washington running for the Governor and other government 
organizations to use as a communication tool to the public - in support of public 
safety, health, and welfare. 


Work with customer agencies to prioritize and keep network resources up tha 
support emergency services. 


Washington State DOT : 

> E-mail and phone systems are the most critical support assets] 
infrastructure recovery. 


ilfor TrSttpo 
inin«mterna 




Public internet access can be jettisoned as a means of roaintair^^ialernal system 
integrity (PIO can be employed to establish and maintmn^ufeljc''information flow). 


Washington State EMD : 





> Network hardware (routers, switches, 

> Servers (Domain controllers, ^change, Dj^umic Host Configuration Protocol 
(DHCP)). 



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Evacuation Phase -- King County Response 


As a result of the scenario induced effects, King County was forced to evacuate its 
downtown facilities with no opportunity to perform maintenance and critical system 
configuration changes. All employees in the downtown areas evacuated, with criticalj^^^ 
management personnel assembling to assess the initial consequences and define a course^^rf 
action to restore services to the employees and the public. Management chose ^^rform the^ 
following: _ \ 

> Define the situation. 

> Identify the major challenges. 

> Identify solutions. 

> Summarize the impact sustained by this c 


The following products were developed: 


Problems encountered by the crisis 





The following facilities were evacuated: 
rJ.ail ^ 




Count^Gourihouse 
^11 of King Street 
KeXiTowers 

f 

Wells Fargo 

Exchange 

Etc. 


All Core cyber-services abandoned and in an immediate state of decay. 

■ Transportation system was affected. 

■ Impacts on employees evacuated. 

■ Work status is undefined, organization is in disarray. 

■ Accounting functions are lost and driven to manual recovery and 
restoration. 


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Challenges facing King County 


Solutions 


> Safety of staff. 

> Restoration of essential services poses challenges in the following 
areas: 

>• Restoration of security and infrastructure. 

> PIO (information to employees and public) / critical function 
restoration / confidence building actions to restore publi^bnfidence.' 

> Legal chaiienge.s and authorities - who will make decision.s^^ing the 
rebuilding process - especially early when maoy~eni ploy ees,are 
without a workplace? 

> Coordination and Leadership with respect to re^ration activities. 

> Prioritization of required actions and acrt^ities^ 

> Human Resources. 





Evaluate and assess faciliti^wd capabilities. 

Contract / defin?altemalive fac^ties - some are defined in plans 
(work through Propeity'Rlanagement). 

Establish initial network connectivity (including home connections). 
Develop work plans and assignments. 

Develop plans to communicate to internal and external audiences. 
Organize internal and external agencies. 

Coordinate with other agencies. 


Impact of the Crisis / Evacuation 


> In a week 

■ Few lost or essential services will be restored. System is in a 
state of decay. 

■ 911 will have been rerouted. 

■ Buses are running. 

■ Sewage treatment is operating. 


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TOPOFF2 CYBEREX - After Action Report 


■ Payroll is questionable - a stop-gap manual method at best will be 
in operation. 

■ Human resources will be strapped. 

■ Court system is not operational. 

• Public safety and confidence in disarray. 

In a month 

■ No significant improvement in the Data Processing^stem. 

• Limited improvement in the other systems. \ 

■ Automatic funds transfer payroll is still a^probl^ - m ^anu^ 
mode. 



It was assessed the County services would take four to six (4 



fully restored. 



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TOPOFF2 CYBEREX - After Action Report 

TOPOFFs Questions during Vignette Three 


• What does DHS “Condition Red" mean to your collective organizations? 

> How might you coordinate your cyber-security operations in this 
threat condition? 

• What are the most critical elements of your IT infrastructure? 

> If your organization’s networks are degrading gracefully, but rapidly, 
what are your priorities for system continuity and restoration? 

• In the event of a wide-scale cyber-attack that disrupts significant portions of your 
critical infrastructure, from a cyber perspective, what are the essential elements of 
information that TOPOFFs need? 

> How do you get this information? 

• How do you regain and maintain public confidence that government organizations 
can respond and provide for adequate security to critical infrastructures, 
particularly the IT infrastructure? 

The major findings for the top officials are as follows; 

> There are corollaries between a physical attack and cyber-attacks as to 
the impact on the continuity of operations of governments and their 
agencies. The ability to react to a physical attack or natural disaster 
has appropriate processes in place with the role of the Federal 
government understood by the State and Local governments, this is not 
true when there is a cyber-attack. 

> The ability to maintain IT infrastructure is predicated on the fact that 
individuals will be able to get to their workspace. In those instances 

' where this is not true, the impact on the IT infrastructure of the various 
government agencies varied as to their ability to do backups and to 
access their systems from alternate locations. 

> During the pre-exercise period, the Federal government was changing 
its official way of responding to cyber-attacks through the standing up 
of DHS and its assimilation of a number of organizations with cyber- 
responsibilities. The attempt by the Federal government is to develop 
an integrated cyber-response capable of many tasks to include support 




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TOPOFF2 CYBEREX - After Action Report 

to both State and Local governments. There is still a need for a single 
point of contact within the Federal government for the dissemination 
of information related to cyber-attacks to the State and Local 
governments. 




xercise 


During Vignette 3, TOPOFFs received a phone call from the Office of the Secretary 
of DHS. In the phone call, he asked participants to provide an update to him on the states of 
the situation and any assistance they may need. The following is their response 


THIS IS AN EXERCISE 

This is in reply to your faxed questions of DTG xxxx May 7. 
Messages) 


We are experiencing several denial of service^nterruptions over several of our 
networks most are tapering off, many'^^bsites have been defaced and Hackers have 
attempted to add additional confusion andHj^la^firetlresponder actions through a 
misinformation campaign over official government sites. King County NOC a key 
information node has been evacuated and is iirtKe process of determining how to 
restore services since no backup^^ilif vie^s ts. 

While the cyber-attack has not affected T' Responder's ability to attend to the WMD 
incident, there has^e mdisr uptionW our ability to respond to other effected 
populations;