ML103020544
| ML103020544 | |
| Person / Time | |
|---|---|
| Site: | Grand Gulf  |
| Issue date: | 10/20/2010 |
| From: | US Dept of Homeland Security, Federal Emergency Management Agency |
| To: | Region 2 Administrator |
| Cecere, Bethanny NSIR/DPR 415-6754 | |
| References | |
| Download: ML103020544 (36) | |
Text
Grand Gulf Nuclear Station Drill Date - September 28, 2010 Radiological Emergency Preparedness (REP) Program After Action Report/
Improvement Plan Published October 20, 2010 Unclassified Radiological Emergency Preparedness Program (REP)
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Grand Gulf Nuclear Station After Action Report/Improvement Plan Published October 20, 2010 Contents Executive Summary 3 Section 1: Exercise Overview 4 1.1 Exercise Details 4 1.2 Exercise Planning Team Leadership 4 1.3 Participating Organizations 5 Section 2: Exercise Design Summary 6 2.1 Exercise Purpose and Design 6 2.2 Exercise Objectives, Capabilities and Activities 6 2.3 Scenario Summary 6 Section 3: Analysis of Capabilities 7 3.1 Drill Evaluation and Results 7 3.2 Summary Results of Drill Evaluation 7 3.3 Criteria Evaluation Summaries 9 3.3.1 Support Jurisdictions 9 3.3.1.1 Riverland Medical Center 9 3.3.2 Private Organizations 12 3.3.2.1 Northeast Louisiana Ambulance Service 12 Section 4: Conclusion 14 Appendix A: Improvement Plan 15 Appendix B: Drill Evaluators and Team Leaders 17 Appendix C: Acronyms and Abbreviations 18 Appendix D: Exercise Plan 19 1 Unclassified Radiological Emergency Preparedness Program (REP)
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EXECUTIVE
SUMMARY
On September 28, 2010 an out-of-sequence Medical Services drill was conducted for the Grand Gulf Nuclear Station (GGNS), located in Port Gibson, Claiborne County, Mississippi. Personnel from the U.S. Department of Homeland Security/Federal Emergency Management Agency (DHS/FEMA) Region VI evaluated all activities. The purpose of the drill was to assess the level of preparedness of local responders to react to a simulated radiological emergency at GGNS.
The previous plume exercise was conducted on September 9, 2009.
Personnel from the State of Louisiana, Riverland Medical Center, Northeast Louisiana Ambulance Service, and Grand Gulf Nuclear Station participated in the drill. Cooperation and teamwork of all the participants was evident during the drill and DHS/FEMA wishes to acknowledge these efforts.
This report contains the final evaluation of the out-of-sequence drill. The participants demonstrated knowledge of their emergency response plans and procedures. There was one Deficiency and three Areas Requiring Corrective Action (ARCA) identified during the drill. One ARCA was corrected during the drill and no Plan Issues were identified.
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SECTION 1: EXERCISE OVERVIEW
1.1 Exercise
Details Exercise Name Grand Gulf Nuclear Station Type of Exercise Drill Exercise Date September 28, 2010 Program Department of Homeland Security/FEMA Radiological Emergency Preparedness Program Scenario Type Radiological Emergency
1.2 Exercise
Planning Team Leadership Lisa Hammond RAC Chair FEMA Region VI Technological Hazards Branch Chief 800 N. Loop 288 Denton, Texas, 76209 940-898-5199 lisa.hammond@dhs.gov Bill Bischof Federal Planning Team Lead FEMA Region VI Technological Hazards Specialist 800 N. Loop 288 4 Unclassified Radiological Emergency Preparedness Program (REP)
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Denton, Texas, 76209 940-898-5562 bill.bischof@dhs.gov Greg Gothard State Planner Louisiana Department of Environmental Quality Environmental Scientist 602 N. Fifth St.
Baton Rouge, Louisiana, 70802 225-219-3627 greg.gothard@la.gov
1.3 Participating
Organizations Agencies and organizations of the following jurisdictions participated in the Grand Gulf Nuclear Station drill:
Risk Jurisdictions Tensas Parish Office of Emergency Preparedness Support Jurisdictions Riverland Medical Center Northeast Louisiana Ambulance Service Private Organizations Grand Gulf Nuclear Station 5 Unclassified Radiological Emergency Preparedness Program (REP)
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SECTION 2: EXERCISE DESIGN
SUMMARY
2.1 Exercise
Purpose and Design The DHS/FEMA Region VI Office evaluated the drill on September 28, 2010 to assess the capabilities of local emergency preparedness organizations in implementing their Radiological Emergency Response Plans and procedures to protect the public health and safety during a radiological emergency involving Grand Gulf Nuclear Station (GGNS). The purpose of this report is to present the results and findings on the performance of the offsite response organizations during a simulated radiological emergency.
2.2 Exercise
Objectives, Capabilities and Activities Exercise objectives and identified Capabilities/REP Criteria selected to be exercised are discussed in the Exercise Plan (EXPLAN), Appendix D.
2.3 Scenario
Summary The drill scenario was developed to evaluate the response of drill participants to an incident requiring evacuation of the public from the Louisiana portion of the 10-mile Emergency Planning Zone surrounding the Grand Gulf Nuclear Station. The drill scenario provided for the evaluation of the Riverland Medical Center and Northeast Louisiana Ambulance Service's ability to transport and treat a radiologically contaminated injured individual.
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SECTION 3: ANALYSIS OF CAPABILITIES
3.1 Drill
Evaluation and Results Contained in this section are the results and findings of the evaluation of all jurisdictions and functional entities that participated in the September 28, 2010, drill evaluation to test the offsite emergency response capabilities of Riverland Medical Center and Northeast Louisiana Ambulance Service to transport and treat a contaminated injured individual.
Each jurisdiction and functional entity was evaluated on the basis of its demonstration of criteria delineated in the exercise evaluation areas as outlined in the April 25, 2002, Federal Register, Radiological Emergency Preparedness: Evaluation Methodology. Detailed information on the exercise evaluation area criteria and the extent of play agreement used in this drill are found in Appendix D of this report.
3.2 Summary
Results of Drill Evaluation The matrix presented in Table 3.1 on the following page, presents the status of all drill evaluation area criteria that were scheduled for demonstration during this drill by all participating jurisdictions and functional entities. Exercise criteria are listed by number and the demonstration status is indicated by the use of the following letters:
M - Met (No Deficiency or ARCAs assessed and no unresolved ARCAs from prior exercise)
D - Deficiency assessed A - ARCAs assessed or unresolved ARCAs from previous exercises P - Plan Issue N - Not Demonstrated 7 Unclassified Radiological Emergency Preparedness Program (REP)
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Table 3.1 - Summary of Drill Evaluation DATE: 2010-09-28 SITE: Grand Gulf Nuclear Station, MS M: Met, A: ARCA, D: Deficiency, P: Plan Issue, N: Not Demonstrated NELA RMC Emergency Operations Management Mobilization 1a1 Facilities 1b1 Direction and Control 1c1 Communications Equipment 1d1 Equip & Supplies to support operations 1e1 M A Protective Action Decision Making Emergency Worker Exposure Control 2a1 Radiological Assessment and PARs 2b1 Decisions for the Plume Phase -PADs 2b2 PADs for protection of special populations 2c1 Rad Assessment and Decision making for the Ingestion Exposure Pathway 2d1 Rad Assessment and Decision making concerning Relocation, Reentry, and Return 2e1 Protective Action Implementation Implementation of emergency worker exposure control 3a1 M A Implementation of KI decision 3b1 Implementation of protective actions for special populations - EOCs 3c1 Implementation of protective actions for Schools 3c2 Implementation of traffic and access control 3d1 Impediments to evacuation are identified and resolved 3d2 Implementation of ingestion pathway decisions - availability/use of info 3e1 Materials for Ingestion Pathway PADs are available 3e2 Implementation of relocation, re-entry, and return decisions.
3f1 Field Measurement and Analysis Adequate Equipment for Plume Phase Field Measurements 4a1 Field Teams obtain sufficient information 4a2 Field Teams Manage Sample Collection Appropriately 4a3 Post plume phase field measurements and sampling 4b1 Laboratory operations 4c1 Emergency Notification and Public Info Activation of the prompt alert and notification system 5a1 Activation of the prompt alert and notification system - Fast Breaker 5a2 Activation of the prompt alert and notification system - Exception areas 5a3 Emergency information and instructions for the public and the media 5b1 Support Operations/Facilities Mon / decon of evacuees and emergency workers, and registration of evacuees 6a1 Mon / decon of emergency worker equipment 6b1 Temporary care of evacuees 6c1 Transportation and treatment of contaminated injured individuals 6d1 M D 8 Unclassified Radiological Emergency Preparedness Program (REP)
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a.b.3.3 Criteria Evaluation Summaries
3.3.1 Support
Jurisdictions 3.3.1.1 Riverland Medical Center MET: None AREAS REQUIRING CORRECTIVE ACTION: 1.e.1, 3.a.1.
ISSUE NO.: 28-10-1e1-A-01 CRITERION: Equipment, maps, displays, dosimetry, potassium iodide (KI), and other supplies are sufficient to support emergency operations.
CONDITION: The Ludlum 12 Survey Meters did not have a Range of Reading sticker affixed.
POSSIBLE CAUSE: Lack of training or oversight. Unaware of requirements.
REFERENCE:
Interim REP Program Manual under Criterion 1.e.1 - Equipment, page III-111. NUREG-0654, H.7,10; J.10.a,b,e, J.11; K.3.a EFFECT: The emergency worker is not able to ensure the equipment is measuring properly. RECOMMENDATION: Affix a Range of Readings sticker to the Ludlum 12 survey meter. Provide training on the proper use of the Range of Readings sticker and operations of the equipment.
ISSUE NO.: 28-10-3a1-A-02 CRITERION: OROs issue appropriate dosimetry and procedures, and manage radiological exposure to emergency workers IAW plans and procedures. Emergency workers periodically and at the end of each mission read and record dosimeter reading. (NUREG-0654, K.3) 9 Unclassified Radiological Emergency Preparedness Program (REP)
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- c. CONDITION: Administrative exposure limits and background levels were not identified to medical personnel at the hospital during the drill.
POSSIBLE CAUSE: Medical center personnel have not been adequately trained on dosimetry.
REFERENCE:
NUREG 0654 K.3.a, b EFFECT: Medical center personnel would not have known when administrivative exposure levels were exceeded.
RECOMMENDATION: Additional training on dosimetry should be provided.
DEFICIENCY: 6.d.1.
ISSUE NO.: 28-10-6d1-D-03 CRITERION: Facility/ORO has the appropriate space, adequate resources, and trained personnel to provide transport, monitoring, decontamination, and medical services to contaminated injured individuals. (NUREG-0654, F.2., H.10., K.5.a.b., L.1., 4) CONDITION: Minimal or no contamination control; no radiological briefing for Emergency Workers (EWs); emergency workers assigned as Monitors were unsure of how to use or read the survey meters; and no range of readings stickers on survey meters. The following discrepancies were observed:
- Emergency workers were not provided a radiological briefing. EWs were not aware of the exposure limits or background levels. No contamination threshold limits were identified.- The Monitor assigned to assist with transfer of patient from ambulance to hospital staff did not frisk the patient or gurney upon transfer from the ambulance to the hospital staff.- During the ambulance survey, the monitor was not sure of what steps to take if 10 Unclassified Radiological Emergency Preparedness Program (REP)
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contamination was found.- The REA Monitor was unaware of how to use swipes and unclear of the procedures for disposal of contaminated waste.- Monitors were not knowledgeable on how to use or read the survey meters when surveying the patient. The controller provided (simulated) reading that the meter was off scale, the monitor did not understand she needed to adjust the meter dial to the next higher scale and coaching was consistently provided throughout the drill.- The REA Monitor did not conduct an initial patient contamination survey until after the first time out was called by the GGNS representative and conducted training on how and why contamination controls are important.- After training, the REA Monitor continued to demonstrate poor surveying techniques and required continued coaching.- The REA medical staff used poor technique in removing potentially contaminated sheets, clothing and medical equipment (neck brace, backboard, etc).- REA nurse may have cross contaminated medical equipment and supplies, prior to changing gloves, by accessing sealed cabinets and following the procedures to request supplies from Buffer Zone staff.- REA staff did not perform glove changes until after time out and training was provided.- Throughout the drill the REA Monitor did not survey the REA staff hands or potentially contaminated areas.- A basin of contaminated saline used to irrigate the wound was left at the patient's feet on the gurney and later on the counter without regard of proper disposal.- The REA Monitor was the first EW to demonstrate the doffing of PPE and exit procedures from the REA. She left the still-running survey meter on the counter and proceeded to step on the "step off" pad without removing the booties or being surveyed by the Buffer Zone nurse. The monitor did not demonstrate the proper procedure to remove the PPE even though the procedures were posted on the wall.- The Buffer Zone nurse's surveying technique was too fast and the distance was inconsistent, at times too far (greater that 1/2 -1") and at times the meter came in contact with the EW being surveyed.- Maintenance staff were tasked with completing the closeout of the REA and Buffer Zone area and had no knowledge or training of proper procedures.- Majority of Emergency Workers departed the area prior to the drill being terminated.
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d.e.f.g.a.b. POSSIBLE CAUSE: Inadequate training and failure to follow procedures.
REFERENCE:
NUREG-0654, F.2; H.10; K.5.a, b: L.1, 4 and Hospital Emergency Department Management of Accidents Procedures for Riverland Medical Center.
EFFECT: The patient would not have been appropriately decontaminated, and the staff could have received contamination by the poor techniques that would result in a spread of contamination to the workers in the area.
RECOMMENDATION: Conduct and reinforce training as needed. Update procedures.
PLAN ISSUES: None NOT DEMONSTRATED: None PRIOR ISSUES - RESOLVED: None PRIOR ISSUES - UNRESOLVED: None
3.3.2 Private
Organizations 3.3.2.1 Northeast Louisiana Ambulance Service MET: 1.e.1, 3.a.1, 6.d.1.
AREAS REQUIRING CORRECTIVE ACTION: 6.d.1.
ISSUE NO.: 28-10-6d1-A-01 CRITERION: Facility/ORO has the appropriate space, adequate resources, and trained personnel to provide transport, monitoring, decontamination, and medical services to contaminated injured individuals. (NUREG-0654, F.2., H.10., K.5.a.b., L.1., 4) CONDITION: The ambulance technician didn't demonstrate a glove change while assessing the victim.
POSSIBLE CAUSE: The checklist referenced by the ambulance technicians should include glove changes.
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c.d.e.f.g.
REFERENCE:
NUREG-0654, K.3.a., 3.b; Tensas Parish Office of Emergency Preparedness, Emergency Medical Services (EMS)/Ambulance Procedure for Response to Radiological Emergencies, Revision 3: September 24, 2010.
EFFECT: Contamination from the victim could have remained on the ambulance technician's gloves transferring contamination to the ambulance and other equipment.
CORRECTIVE ACTION DEMONSTRATED: Training was conducted and several glove changes were subsequently demonstrated throughout the drill.
DEFICIENCY: None PLAN ISSUES: None NOT DEMONSTRATED: None PRIOR ISSUES - RESOLVED: None PRIOR ISSUES - UNRESOLVED: None 13 Unclassified Radiological Emergency Preparedness Program (REP)
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SECTION 4: CONCLUSION Based on the results of the drill, and the assessment of a deficiency against Riverland Medical Center, the Medical Center will be required to redemonstrate and correct the issues identified within this report. The Northeast Louisiana Ambulance Service satisfactorily demonstrated their required criteria and no additional demonstration is necessary until the next regularly scheduled drill/exercise at this location.
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APPENDIX A: IMPROVEMENT PLAN Issue Number: 28-10-1e1-A-01 Criterion: 1e1 ISSUE: The Ludlum 12 Survey Meters did not have a Range of Reading sticker affixed.
RECOMMENDATION:
Affix a Range of Readings sticker to the Ludlum 12 survey meter. Provide training on the proper use of the Range of Readings sticker and operations of the equipment.
CORRECTIVE ACTION DESCRIPTION:
CAPABILITY:
PRIMARY RESPONSIBLE AGENCY:
CAPABILITY ELEMENT:
START DATE:
AGENCY POC:
ESTIMATED COMPLETION DATE:
Issue Number: 28-10-3a1-A-02 Criterion: 3a1 ISSUE: Administrative exposure limits and background levels were not identified to medical personnel at the hospital during the drill.
RECOMMENDATION:
Additional training on dosimetry should be provided.
CORRECTIVE ACTION DESCRIPTION:
CAPABILITY:
PRIMARY RESPONSIBLE AGENCY:
CAPABILITY ELEMENT:
START DATE:
AGENCY POC:
ESTIMATED COMPLETION DATE:
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Issue Number: 28-10-6d1-D-03 Criterion: 6d1 ISSUE: Minimal or no contamination control; no radiological briefing for Emergency Workers (EWs);
emergency workers assigned as Monitors were unsure of how to use or read the survey meters; and no range of readings stickers on survey meters. The following discrepancies were observed:
- Emergency workers were not provided a radiological briefing. EWs were not aware of the exposure limits or background levels. No contamination threshold limits were identified.- The Monitor assigned to assist with transfer of patient from ambulance to hospital staff did not frisk the patient or gurney upon transfer from the ambulance to the hospital staff.- During the ambulance survey, the monitor was not sure of what steps to take if contamination was found.- The REA Monitor was unaware of how to use swipes and unclear of the procedures for disposal of contaminated waste.- Monitors were not knowledgeable on how to use or read the survey meters when surveying the patient. The controller provided (simulated) reading that the meter was off scale, the monitor did not understand she needed to adjust the meter dial to the next higher scale and coaching was consistently provided throughout the drill.- The REA Monitor did not conduct an initial patient contamination survey until after the first time out was called by the GGNS representative and conducted training on how and why contamination controls are important.- After training, the REA Monitor continued to demonstrate poor surveying techniques and required continued coaching.- The REA medical staff used poor technique in removing potentially contaminated sheets, clothing and medical equipment (neck brace, backboard, etc).- REA nurse may have cross contaminated medical equipment and supplies, prior to changing gloves, by accessing sealed cabinets and following the procedures to request supplies from Buffer Zone staff.- REA staff did not perform glove changes until after time out and training was provided.- Throughout the drill the REA Monitor did not survey the REA staff hands or potentially contaminated areas.- A basin of contaminated saline used to irrigate the wound was left at the patient's feet on the gurney and later on the counter without regard of proper disposal.- The REA Monitor was the first EW to demonstrate the doffing of PPE and exit procedures from the REA. She left the still-running survey meter on the counter and proceeded to step on the "step off" pad without removing the booties or being surveyed by the Buffer Zone nurse. The monitor did not demonstrate the proper procedure to remove the PPE even though the procedures were posted on the wall.- The Buffer Zone nurse's surveying technique was too fast and the distance was inconsistent, at times too far (greater that 1/2 -1") and at times the meter came in contact with the EW being surveyed.- Maintenance staff were tasked with completing the closeout of the REA and Buffer Zone area and had no knowledge or training of proper procedures.- Majority of Emergency Workers departed the area prior to the drill being terminated.
RECOMMENDATION:
Conduct and reinforce training as needed. Update procedures.
CORRECTIVE ACTION DESCRIPTION:
CAPABILITY:
PRIMARY RESPONSIBLE AGENCY:
CAPABILITY ELEMENT:
START DATE:
AGENCY POC:
ESTIMATED COMPLETION DATE:
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APPENDIX B: DRILL EVALUATORS AND TEAM LEADERS DATE: 2010-09-28, SITE: Grand Gulf Nuclear Station, MS LOCATION EVALUATOR AGENCY Riverland Medical Center
- Bill Bischof Brad DeKorte Elsa Lopez DHS/FEMA DHS/FEMA DHS/FEMA Northeast Louisiana Ambulance Service
- Linda Gee DHS/FEMA* Team Leader 17 Unclassified Radiological Emergency Preparedness Program (REP)
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APPENDIX C: ACRONYMS AND ABBREVIATIONS Acronym Meaning ARCA Areas Requiring Corrective Action BZ Buffer Zone DRD Direct Reading Dosimeter EMD Emergency Management Director EMS Emergency Medical Services EMT Emergency Medical Technician ER Emergency Room EW Emergency Worker GE General Emergency GGNS Grand Gulf Nuclear Station NELA Northeast Louisiana Ambulance Service NP Nurse Practitioner PPE Personal Protective Equipment REA Radiation Emergency Area RMC Riverland Medical Center TLD Thermoluminescent Dosimeter 18 Unclassified Radiological Emergency Preparedness Program (REP)
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APPENDIX D: EXERCISE PLAN 19 Unclassified Radiological Emergency Preparedness Program (REP)
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