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with respiratory protection when the circumstances warrant it. As Department of Emergency Management (ACDEM), identified
such, chemical distribution companies should conduct evaluations several issues and areas for improvement. Most responders
to determine the need to train drivers to don appropriate PPE and agreed that interagency communication and coordination
respond to chemical spills or releases during unloading operations. went well on the day of the incident, but they identified some
Where mitigating incidents is feasible, chemical distributors challenges communicating the incident to the public as well as
should provide the appropriate PPE for doing so on CTMVs. updating the local hospital. The report identified issues with the
Where mitigating incidents is not feasible, chemical distributors CodeRED® community notification system. CodeRED is a mass
should ensure that drivers have access to, and are properly notification system provider that can alert and inform subscribers of

trained to wear, emergency escape respirators on CTMVs to safely emergencies or severe weather through a variety of methods (e.g.,
115
evacuate in the event of an incident. Furthermore, in addition to voice, text, email, mobile alerts). Although Atchison County uses
chemical distribution companies supplying respirators on CTMVs, CodeRED, notifications did not go out at the time of the incident. In
facilities can also store emergency respiratory protection near the absence of CodeRED functioning, ACDEM and local emergency
unloading areas. If properly trained, drivers can access emergency responders utilized social media and local radio and television to
respirators to safely escape in the event of an accidental release. communicate details about the emergency. As identified by ACDEM
in the AAR & IP, CodeRED notifications did not go out due to a lack

The CSB found Harcros’ respiratory protection policy for drivers of training on the system. Progress has been made with respect
to be inadequate in part because, as described, Harcros relies on to CodeRED since the incident. ACDEM has completed additional
communications made by its customers to determine workplace training on the CodeRED system to ensure it will work correctly
hazards. Such reliance may prove misplaced, however, where and has increased efforts to publicize the notification system.
parties do not actively establish who is responsible for making
the communication; an omission on the part of one may be Though some emergency responders quickly became aware
interpreted as a commission by the other. As described, there must of the chemicals involved in the reaction, the exact chemicals
be shared responsibility between chemical distribution companies and concentration of chemicals contained in the cloud, as
and facility management to ensure chemicals are unloaded well as the exposure effects on the community, remained

safely. Accordingly, the CSB recommends that Harcros establish a largely unknown throughout the incident. As part of the after-
process whereby the respiratory hazards associated with chemical action review, hospital staff reported that they were not kept
unloading at each customer’s site are proactively evaluated. informed of the status of potential victims and decontamination
The evaluations should determine whether drivers might need procedures for the chemicals. In addition, incident command did
emergency escape respirators in the event of an accidental not directly communicate information regarding the released
reaction and/or release of chemicals. Equipment and training for chemicals to the hospitals until about 1 and a half to 2 hours
such protection should be provided, as appropriate, in accordance after the incident began. The emergency responders set up

with OSHA’s Respiratory Protection Standard. Finally, so as to avoid triage stations in town to evaluate members of the public prior
the problems faced by MGPI operators, the equipment should be to hospital transport. Atchison Hospital, though overwhelmed
stored in an area of the CTMV that allows for immediate access. initially, was able to decontaminate and treat all arriving
patients. According to ACDEM, after the incident, it set up a plan
5.5 EMERGENCY PLANNING AND RESPONSE ANALYSIS with local hospitals to have a representative at the emergency
5.5.1 INCIDENT AFTER ACTION REVIEW AND IMPROVEMENTS
operations center or command post, depending on the size
Following the October 2016 incident, city and county emergency of the event. This is meant to ensure that the representative is
responders conducted a post-incident critique to examine issues up-to-date on all information to relay back to the hospital.
identified during the response. Though the response was largely

viewed as a success by responders, the After-Action Report and
Improvement Plan (AAR & IP), issued by the Atchison County 115 Onsolve Code Red Product Description. https://www.onsolve.com/solutions/products/
codered/ (accessed October 30, 2017).
CSB MGPI Processing Case Study 29