"HSEEP AAR-IP Template"
AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 Alaska Mass Rescue Operation (MRO) Exercise 2009 AFTER ACTION REPORT AND IMPROVEMENT PLAN Report Date: July 15, 2009 Exercise Date: April 27-29, 2009 Locations: Seattle, WA Juneau, AK Ketchikan, AK 1 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 HANDLING INSTRUCTIONS 1. The title of this document is Alaska Mass Rescue Operations Exercise 2009After Action Report (AAR). 2. The information gathered in this AAR is un-classified and may be shared with others to improve mass rescue planning and response in other port communities. 3. Points of Contact: Federal POC: Rick Janelle 17th Coast Guard District PO Box 25517 Juneau, AK 99802 907-463-2808 email@example.com Industry POC: Christian Mollitor Holland America Line 300 Elliott Ave. West Seattle, WA 98119 206-286-3460 CMollitor@HollandAmerica.com Community POCs: Jim Hill Steve Corporon Chief, Ketchikan Fire Department Ports and Harbors Director 334 Front Street 2933 Tongass Ave. Ketchikan, AK 99901 Ketchikan, AK 99901 907-225-5940 907-228-5632 JIMH@city.ketchikan.ak.us firstname.lastname@example.org 2 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 CONTENTS Administrative Handling Instructions.................................................................. 2 Contents................................................................................................................... 3 Executive Summary................................................................................................ 4 Section 1: Exercise Overview .............................................................................. 11 Exercise Details ...................................................................................................................... 11 Exercise Planning Team ......................................................................................................... 12 Participating Organizations .................................................................................................... 13 Section 2: Exercise Design Summary ................................................................. 15 Exercise Purpose and Design.................................................................................................. 15 Scenario, Capabilities and Activities Identified for Demonstration ....................................... 16 Section 3: Analysis of Objectives......................................................................... 18 Objective 1 ............................................................................................................................. 18 Objective 2 ............................................................................................................................. 24 Objective 3 ............................................................................................................................. 29 Objective 4 ............................................................................................................................. 34 Objective 5 ............................................................................................................................. 37 Objective 6 ............................................................................................................................. 41 Objective 7 ............................................................................................................................. 42 Objective 8 ............................................................................................................................. 43 Objective 9 ............................................................................................................................. 47 Objective 10 ........................................................................................................................... 48 Section 4: Conclusion ........................................................................................... 50 Appendix A: Improvement Plan ......................................................................... 51 Appendix B: Exercise Design Lessons Learned................................................. 52 3 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 EXECUTIVE SUMMARY The Alaska Mass Rescue Operation (MRO) Exercise 2009 was a full scale exercise that simulated the grounding of the cruise ship “Alaska Cruiser” south of Ketchikan on Snail Rock, Alaska. The role of the fictitious ship and its company, “Independent Cruise Lines”, was role- played by the staff of Holland America Line of Seattle, WA. On the first day of exercise play, search and rescue (SAR) and pollution related response planning were exercised. On day two, operations focused on conducting coordinated shore side operations to support the landing, accountability, care, and sheltering for the 2,500 passengers and crew evacuated from the cruise ship. Several hundred local Ketchikan volunteers, each carrying multiple name cards, simulated the 2,500 passengers/crew. Over the past 10 years, the maritime industry and the Alaska federal, state and local response agencies have jointly developed recommendations for MRO procedures, including an accountability process, communication best practices, common Unified Command objectives and missions, joint quick response guides cards and other documents to support response coordination. This exercise was the culmination of these past mass rescue workshops and exercises, and an opportunity to apply and evaluate these joint efforts as well as lessons learned from real events and other MRO exercise recommendations. This exercise planning process was truly a joint effort of the U.S. Coast Guard (USCG), Holland America Line (HAL), City of Ketchikan (City) fire/ports and harbors/police/medical departments, Ketchikan Gateway Borough fire departments, Customs and Border Protection (CBP), and Canadian Coast Guard to: • Evaluate response plans and capabilities for a mass rescue operation. • Apply lessons learned from actual events and previous MRO exercises to improve response coordination between industry and local, state, and federal and Canadian SAR agencies. • Provide real time training to staff. Since MRO incidents are low probability events, exercises provide a valuable tool to practice and gain experience. • Fulfill USCGD17’s major 3 year SAREX Full Scale Exercise requirements mandated by COMDTINST M 3010.13B. The exercise was conducted in two major phases. • Phase one, conducted on April 28, utilized a command post format and focused on joint SAR coordination and planning as well as the initiation of major marine casualty response planning that included oil spill response, environmental protection, salvage planning, information management, and media relations. Phase One concluded with the development of a detailed plan to transport evacuees to shore and the initial planning for the associated contingencies listed previously. 4 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 • Phase Two, conducted on April 29, was a full scale field exercise to practice and evaluate a coordinated shore side response for the accountability and care of evacuees. This phase started with the arrival of a rescue boat at the landing site with local volunteers’ role playing evacuees. During this phase, the response organization implemented plans to provide medical services, transport, shelter, care, and account for evacuees. Phase Two was intended to end with the 100% accountability of all passengers and crew and the further development of plans for salvage, oil spill, environmental protection, media relations, and information support services. To simulate real world conditions, this exercise was initiated in real time from three geographically separated locations in Seattle, WA and Juneau and Ketchikan, Alaska. A simulation cell was established in Ketchikan that represented the ship and on scene assets. This separation realistically provided the opportunity to evaluate the coordination and communication pathways normally encountered in a real event. There was no actual cruise ship used in this exercise, but a Holland America Line Master, Chief Engineer, and Medical Officer role played the critical positions and provided accurate assessments from the simulation cell. This exercise permitted several organizations to exercise their individual response plans and /or conduct realistic training opportunities. Examples include the Ketchikan General Hospital and Ketchikan Indian Community Clinic exercising of mass care procedures and CBP training of their officers in the process of “humanitarian paroles” of foreign crew members. The Alaska MRO 2009 core objectives exercised were: 1. Establish and coordinate a unified command in response to a Mass Rescue Operation (MRO) and maintain a common operating picture between the response centers in Juneau, Ketchikan and Seattle. 2. Coordinate rescue and assistance action plans for the evacuation and transportation of evacuees from the (simulated) incident site to a designated landing/recovery sites. 3. Account for passengers and crew with 100% accuracy by the end of the exercise. 4. Establish and operate incident facilities that include the Industry Command Centers, Coast Guard Search and Rescue Command Centers, and the Unified Command/ Incident Command Post in the Ketchikan. 5. Implementation of a shore-side support plan for evacuees that including triage and medical services, local transportation, sheltering and personal care. 6. Development of joint pollution response, environmental protection and other plans to address the scenario consequences. 7. Establish and operate a joint “media plan” for response to an elevated public affairs demand to the given scenario. 5 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 8. Establish timely communications and information exchange between the ship, industry EOC, response agencies, and impacted port community. 9. Establish an industry Emergency Call Center and website to serve as a point of information for family and friends of guests and crewmembers sheltered in Ketchikan. 10. Validate the Global Maritime Distress and Safety System (GMDSS) notification system. Major Strengths. Throughout the entire exercise process, from conceptual planning to exercise execution, all participants demonstrated a high level of cooperation and commitment. Everyone remained focused on the value of the exercise and the importance of keeping the event as realistic as possible in order to identify strengths and areas for improvement. • Strengthened Working Relationships. The Unified Command (UC) response organization demonstrated that a deep and wide “talent pool” of emergency responders is readily available within major cruise lines and the Alaska maritime industries, as well as at the community, state and federal agency levels. This pool of skilled and trained professionals exhibited an extremely high degree of interagency cooperation, that when combined with individual knowledge, experience, and commitment, enabled the UC to resolve problems and provide a “best” response to the challenging scenario. Figures 1: City and Borough of Ketchikan Landing Site Preparations. • Ketchikan Shore-side Response Capability. The City of Ketchikan, Ketchikan Gateway Borough, and local public and private organizations demonstrated the ability to organize and support the key elements for the shore side operations for a successful maritime mass rescue response. A landing site was identified and secured, emergency medical services dispatched, transportation arranged, sheltering capability established, and an initial accountability process implemented. • Search and Rescue Planning. The USCG Rescue Coordination Center / Sector Juneau Command Center and the cruise line industry effectively communicated and developed a response plan for the evacuation and safe transportation to shore of all passengers and non-essential crew members. The use of liaison officers at the industry emergency 6 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 operations center and the USCGD17 RCC provided valuable and is encouraged as a best practice. • Accountability Coordination. Overall, exercise participants did an excellent job of tracking the evacuees. • Special Needs Support. The cruise industry demonstrated the ability to identify passengers with special needs, and to communicate this information accurately. The City of Ketchikan exceeded all expectations in the development of a fully-inclusive emergency preparedness plan that integrated people with special needs, people with disabilities, the medically fragile, and individuals who were vulnerable at the moment. By stressing this population during the exercise, the State of Alaska and the community of Ketchikan highlighted the importance of including requirements for special needs personnel in the response planning process. • Landing Site and Reception Center Management. This was both a strength and area for improvement. To the best our knowledge, this was the first exercise of this size to examine the management and integration of landing sites and reception centers in the MRO process. The main strength exhibited was the ability of the community to identify suitable locations and then to rapidly make them operational. The foundation was poured for a better plan to improve operations at landing sites and reception centers during this exercise. • Oil and Environmental Response. The response procedures and management for oil spill response, including environmental and wildlife protection, demonstrated a mature, well trained and practiced organization. Personnel and organizations involved in these missions quickly organized, implemented response plans, and communicated appropriate recommendations to the Unified Command. • GMDSS Alert. This exercise validated the capability to detect, identify, and respond to a Global Maritime Distress and Safety System (GMDSS) marine distress notification initiated by the Canadian Coast Guard vessel TANU in the vicinity of Snail Rocks. Emergency GMDSS activations are few and “live” tests of the world wide process validated and provided an important training opportunity for the International search and rescue organizations. Primary Areas for Improvement The primary areas identified for improvement, including recommendations, are as follows: • Initial Response Coordination. The initial phase of any incident is a challenge. During a major marine casualty, conditions on scene are dynamic and on scene personnel are fully involved in responding to the incident. On shore, industry and government response personnel are starved for accurate information to initiate appropriate response efforts. With initial operations conducted from geographically separated industry and 7 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 USCG command centers, success is often determined by how quickly and accurately information can be exchanged and then how efficiently response agencies utilize this information to initiate actions and organize the appropriate command organization. 1. Communications Coordination. Current contingency plans list one or two key emergency contact numbers for each agency. During this exercise, the extended use of these limited incoming lines, or utilization of a central operator (switchboard) initially slowed the flow of rapidly changing information. Recommendations: To improve and facilitate the flow of information, each agency/organization must quickly distribute an accurate communications (telephone/cell/email) plan to all their response partners. This allows direct contact between responders at similar levels in the organization. Additionally, to aid the exchange of information, especially manifests and other intensive information, continued investigation into the use of “off the shelf” web based technology is recommended. This web based technology use is a recommendation from past exercises and events, but remains an issue in part due to the inability to agree and select a common application, and concerns about security of systems. Figure 2: Unified command meeting at Ted Ferry Civic Center, Ketchikan, AK. 2. Unified Command Activation. For a typical Alaskan based response, organizations that comprise the unified command will initially be remote from one another - the industry operates from their emergency center, the USCG and State from the federal command center, and the local community, when activated, from their identified emergency operations center (EOC). During this exercise, there was considerable discussion prior to the event on the mechanics of standing up the response organization with remotely located Unified Commanders, including where, when and how the UC would transition to a common location. As an exercise artificiality to facilitate training, the UC assembled in Ketchikan perhaps earlier than can be expected in a real event. In an actual event, it will be difficult for senior decision makers to transition to another location until the SAR phase is well under control. But at the same time, a local response presence will be required to direct local activities, including oil and environmental response, evacuee care, accountability, etc. Recommendations: Establish a working group to investigate organizational options for the early stages of a response with remotely located unified commanders. Identify additional training or development of job aids that may be required. • Landing Site and Reception Center Management. One weak point in the landing site 8 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 and reception center organization and management was the failure to appoint, communicate and identify an overall site “manager” at each location. This “manager” has the responsibility to oversee site operations in accordance with Unified Command priorities, ensures the jurisdictional requirements for all involved agencies are met and coordinated, and quickly and fairly resolves any discrepancies that arise between agencies. The identity and authority of this manager must be communicated to all agencies represented at the sites. To help identify this person from the general public, a uniform or identifying vest should be utilized. Recommendation: A joint working group should develop guidance documents and job aids for the establishment and management of landing sites and reception centers. Included in this document should be considerations for identifying the Group Supervisor along with associated responsibilities, organizational charts, checklists and reporting information. • Accountability Coordination. Overall, exercise participants did an excellent job of tracking the evacuees. Although 100% accountability was not possible due to a design failure with the exercise, the process established by the industry players did identify that some evacuees were missing. The main concern was that the UC failed to provide a clear explanation to all organizations supporting evacuee care at the landing site and reception center for how the accountability process would be managed and coordinated with the other functions (medical care, passenger offload, landing priority, etc) also being conducted at each site. This lack of internal communication resulted in confusion, and at times, heated discussions about conducting concurrent operations at these sites. Recommendation: Establish a working group of stakeholders too investigate options to improve the existing Alaska Standard Accountability Process. As a minimum it should include check lists for coordination considerations, informational reporting requirements, accountability process management (manual, electronic), and other considerations identified in this report. Figures 3: Shore Side Emergency Medical Response • Evacuee Care Coordination. A unique aspect to a mass rescue operation involving large passenger vessels is the concept of industry “Care Teams” dispatched to the scene for evacuee support. These care teams are composed of skilled personnel, but their 9 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 functional capabilities, coordination procedures with local emergency responders, and reporting chain within the response organization is not clearly understood. Recommendation. The coordination and inclusion of industry Care Teams in the response organization should be defined and included in response plans, and the functional aspects of Care Teams should be reviewed at pre-season meetings or other venues. General Recommendations for Improvement Plan • That USCGD17 coordinate joint work groups to initiate actions on the recommendations in the report, with special consideration for the coordination of efforts in managing the accountability process and operations of the landing sites and reception centers. • That all agencies and organization involved in this exercise participate in the work groups. • That all agencies and organization involved in this exercise initiate improvement actions identified during their respective internal exercise evaluation and debrief. Executive Summary Conclusion The Alaska Mass Rescue Operation 2009 exercise was successfully conducted. It brought together an extensive emergency response and management system that demonstrated the ability to effectively mitigate a catastrophic Mass Rescue Operation. Importantly, it provided the agencies and personnel a process of improvement, the opportunity to work together, develop an understanding of capabilities, experience first hand the need for coordinated improvement, apply lessons learned to efficiently mitigate an incident, and an opportunity to professionally exchange their business cards before and incident. 10 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 SECTION 1: EXERCISE OVERVIEW Exercise Details Exercise Name: Alaska Mass Rescue Operations Exercise 2009 Type of Exercise: Full Scale Exercise Exercise Dates: April 27-29, 2009 Locations • Seattle, WA: Holland America Line Emergency Operations Center • Juneau, AK: Sector Juneau and 17th Coast Guard District • Ketchikan, AK: Ted Ferry Civic Center and various field sites. Sponsors • U.S. Coast Guard Sector Juneau • Holland America Line • City of Ketchikan, AK • Customs and Border Protection / Office of Field Operations Program • U.S. Coast Guard Mass Rescue Operation • National Search and Rescue (SAR) program • International Safety Management System for Passenger Vessels Funding • U.S. Coast Guard Exercise and Evaluation Program • Department of Homeland Port Security Grant Program • City of Ketchikan • Individual companies and organizations funded their own participation. Mission Response • Search and Rescue Planning • Marine Environmental Protection • Accountability • Shore Side Evacuee Support. Capabilities • Search and Rescue • Unified Command organization and communication. • Accountability of evacuees • Shore side support and care of evacuees • Marne environmental protection Scenario Type: Mass rescue operations (MRO) response. 11 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 Exercise Planning Team Exercise Director: Rick Janelle, USCG D17, Rick.N.Janelle@uscg.mil Exercise Co-Director: Christian Mollitor, Holland America Line, email@example.com Lead Evaluator: Kevin Kearney, USCG D17, firstname.lastname@example.org Design Team Members Prash Karnik Holland America, Pkarnik@HollandAmerica.com; Sally Van Bonheeman Holland America, email@example.com; Arie Beukelman Holland America, firstname.lastname@example.org; John Warton Princess Cruises, email@example.com; Jim Hill City of Ketchikan, firstname.lastname@example.org; Steve Corporon City of Ketchikan, email@example.com; Dave Timmerman City of Ketchikan, firstname.lastname@example.org; Les Zetterberg City of Ketchikan, email@example.com; Bev Crum City of Ketchikan Hospital, BCrum@peacehealth.org Rick Erickson Cruise Line Agencies of Alaska, firstname.lastname@example.org; Tracy Clark US Customs and Border Protection, email@example.com; Bob Ayres Canadian Coast Guard, Bob.Ayres@dfo-mpo.gc.ca; Jeff Nemrava Canadian Coast Guard, Jeff.Nemrava@dfo-mpo.gc.ca; Edwardson, Robert USCG Sector Juneau, Robert.H.Edwardson@uscg.mil Katelyn South USCG PACAREA, Katelyn.firstname.lastname@example.org Nora Gomez USCG PACAREA, Nora.email@example.com Russell Levin USCG HQ, CG622, Russell.S.Levin@uscg.mil Thomas Walker USCG D1, Thomas.J.Walker@uscg.mil Dennis Spain USCGD5, Dennis.firstname.lastname@example.org Paul Culver USCG D7, Paul.M.Culver@uscg.mil George (Rob) Lee USCG D11, George.R.Lee@uscg.mil Emily Saddler USCG D13, Emily.C.Saddler@uscg.mil George Butler USCG D14, email@example.com 12 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 Participating Organizations The follow agencies participated in the Alaska Mass Rescue Operation 2009 exercise. While there were also many sub-groups of some of these major agencies that participated. Due to the significant size and complexity of this exercise in both scope and geography, it was difficult to determine all individual players and agencies that were represented To those who have been omitted we appreciate your assistance and apologize for the over sight. 1. USCG: 17th Seventeenth Coast Guard District Sector Juneau ISC Ketchikan MSD Ketchikan Station Ketchikan AIRSTA Sitka USCGC ACUSHNET USCGC CUTTYHUNK USCGC ANTHONY PETIT USCGC NAUSHON USCGC ANACAPA USCG Auxiliary Sector Seattle 13th Coast Guard District 2. Federal Partner Agencies: US Customs and Border Protection / Office of Field Operations US Department of the Interior: U.S. Fish and Wildlife Service National Oceanic and Atmospheric Administration (NOAA) Transportation Security Administration (TSA) U.S. Forest Service (USFS) National Transportation and Safety Board (NTSB) Federal Bureau of Investigations (FBI) American Red Cross 3. State of Alaska: Alaska State Troopers Alaska Department of Environmental Conservation (DEC) State Emergency Operations Center (EOC) Alaska Department of Health and Human Services Alaska Department of Fish and Game Alaska Marine Highways 4. City of Ketchikan: Ketchikan Fire Department Ports and Harbors Department Ketchikan Police Department 5. Ketchikan Gateway Borough North Tongass Volunteer Fire Department South Tongass Volunteer Fire Department Parks and Recreation Department Ketchikan Gateway Borough School District 13 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 6. Other Local Ketchikan Agencies Ketchikan General Hospital Ketchikan Indian Community (KIC) Ketchikan Senior Citizens Center City of Saxman 7. Other Alaska Agencies Providence Valdez Medical Center, Valdez, AK Bartlett Memorial Hospital, Juneau, AK City of Valdez, AK City of Saxman, AK 8. Canada and Others Canadian Coast Guard RCC Victoria Canadian Coast Guard Cutter TANU Canadian Consulate United Kingdom Consulate, San Francisco 9. Industry: Holland America Line Princess Cruises Royal Caribbean Cruise Line Princess Tours Cruise Line Agencies of Alaska Southeast Stevedoring Alaska Steamship Response Allen Marine Lines Alaska Discovery Tours SEAPRO, Inc. Marine Exchange of Alaska Southeast Pilots Association SEATAGS Safety Systems ECM Maritime Services, LLC Number of Participants • Players - 207 • Controllers - 30 • Evaluators - 12 • Facilitators - 5 • Observers - 15 • Victim Role Players - 175 14 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 SECTION 2: EXERCISE DESIGN SUMMARY Exercise Purpose and Design Over the past 10 years, the maritime industry and the Alaska federal, state and local response agencies have jointly developed recommendations for MRO procedures, including an accountability process, communication best practices, common Unified Command objectives and missions, joint quick response cards and other documents to support response coordination. This exercise was the culmination of these past mass rescue workshops and tabletop exercises, and an opportunity to apply and evaluate these joint efforts as well as lessons learned from real events and other MRO exercise recommendations. This exercise was jointly developed by the combined efforts of U.S. Coast Guard (USCG), Holland America Line (HAL), City and Borough of Ketchikan (CBK) fire/ports and harbors/police/medical departments, and Customs and Border Protection (CBP) to: • Evaluate response plans and capabilities for a mass rescue operation. • Improve response coordination between industry and local, state, and federal and Canadian SAR agencies and personnel to a mass rescue incident with emphasis on communications, shore-side coordination and evacuee tracking. • Provide real time training to staff. Since MRO incidents are low probability events, exercises provide a valuable tool to practice and gain experience. • Fulfill USCGD17’s major 3 year SAREX Full Scale Exercise requirements mandated by COMDTINST M 3010.13B Scenario Requirements. The scenario was designed to meet the following criteria: • Realistic as possible. • Progressive and unfold in near real time. • Activate as many response partners as possible. • Lead to a controlled evacuation. • Involve Multiple Functions. o Fire o Pollution o Medical o Evacuation o Special needs 15 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 Basic Scenario. At 1800 on 26 April 2009, the M/V ALASKA CRUISER departed Vancouver enroute Alaska for a 7 day cruise of SE Alaska with 1801 passengers, including 37 physically handicapped persons, and 700 crew members on board. At 0658, on April 28, 2009, while transiting Revillagigedo Channel, Alaska in position 54- 57.9N, 131-06.07W, an explosion occurs in the forward main switch board located on B deck in Main Fire Zone 3. The explosion resulted in a “black out” on the ship, loss of propulsion, and a localized fire in the compartment with smoke moving into the accommodation areas on the decks 1 and 2 of Main Fire Zone (MFZ) 3. The ship failed to regain power, drifted with the tide and currents, and eventually grounded on Snail Rocks. Throughout the scenario timeline, the on board status of the passengers and crew is reported. Falling tides required the evacuation of passengers and non-essential crew. Exercise players were free to utilize any response asset that was available in real time, including transiting vessels, to plan for the rescue of the 2500 passengers and crew. Approximately 170 local volunteers were recruited from local schools, CG units, senior citizens, church groups, and private citizens. Volunteers included handicapped personnel requiring exercise control to establish tight safety procedures. Capabilities Exercised and Associated Objectives. • Search and Rescue (SAR). o Objective 2, Objective 3, Objective 8, Objective 10 • Unified Command (UC) organization and communication. o Objective 1, Objective 4, Objective 7, Objective 8, Objective 9 • Accountability of evacuees. o Objective 3 • Shore side support and care of evacuees. o Objective 5 • Marine Environmental Protection (MEP). o Objective 6 Exercise Objectives: 1. Establish and coordinate a unified command in response to a Mass Rescue Operation (MRO) and maintain a common operating picture between the response centers in Juneau, Ketchikan and Seattle. 2. Coordinate rescue and assistance action plans for the evacuation and transportation of evacuees from the (simulated) incident site to a designated landing/recovery sites. 3. Account for passengers and crew with 100% accuracy by the end of the exercise. 4. Establish and operate incident facilities that include the Industry Command Centers, Coast Guard Search and Rescue Command Centers, and the Unified Command/ Incident Command Post in the Ketchikan. 16 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 5. Implementation of a shore-side support plan for evacuees that including triage and medical services, local transportation, sheltering and personal care. 6. Development of joint pollution response, environmental protection and other plans to address the scenario consequences. 7. Establish and operate a joint “media plan” for response to an elevated public affairs demand to the given scenario. 8. Establish timely communications and information exchange between the ship, industry EOC, response agencies, and impacted port community. 9. Establish an industry Emergency Call Center and website to serve as a point of information for family and friends of guests and crewmembers sheltered in Ketchikan. 10. Validate the Global Maritime Distress and Safety System (GMDSS) notification system. Figures 4: Exercise Control / Simulation Cell role plays actions of MV ALASKA CRUISER. 17 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 SECTION 3: ANALYSIS OF OBJECTIVES AND CAPABILITIES This section of the report reviews each exercise objective and discusses those issues common to all exercise participants with the goal to improve interagency response coordination and efficiency. Individual agency / organization comments that address specific internal procedures or policies are not included. The order of the observations is not prioritized. OBJECTIVE 1: Establish and coordinate a unified command in response to a Mass Rescue Operation (MRO) and maintain a common operating picture between the response centers in Juneau, Ketchikan and Seattle. Capability: Unified command organization and communication. Summary: This objective and capability was performed successfully but with some challenges noted. The exercise illustrated the challenges of managing initial multiple operation centers and response sites, and the importance of communicating accurate critical information. This exercise attempted to reflect the real world conditions of the initial 24-30 hours of a response by having players start from their normal locations, ramp up resources, establish communications to initiate coordinated emergency response plans and establish the unified command, and finally to transition to a common location. Since the exercise simulated the initial 24-30 hours, a full incident action plan (IAP) was not expected by exercise end. The exercise was set up by design to encompass one operational period but split over two exercise days. This was done to allow for the normal start up issues of a new ICS team coming together for the first time and to provide time for on the job training and coaching. The Coast Guard ICS coach stated that there was a very steep learning curve the first day but the incident response team made enormous progress. The second exercise day saw the Unified Command gelling as additional personnel were ordered in. Due to the limited time available for exercise play, response activities, especially the transition of Unified Command to Ketchikan, were compressed. Command posts in Juneau, Ketchikan and Seattle were set up a day in advance to permit training and documentation of the process. This compression permitted players the benefit of working together longer and increased face to face coordination with local responders. Observation 1.1: Since incidents of this severity are rare, the response community has developed tools and job aids at past workshops to assist response organizations with both 18 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 initial response actions and unified command organization. These documents include: • Multi-Agency Quick Start Guide for Passenger Vessel Emergencies • Unified Command Missions, Objectives and Tasks • Communication Best Practices • Passenger Accountability Process The purpose for these documents is to provide traction for responders, to align response actions and expectations, and to avoid duplication of effort and competition for limited resources. However, the use of these documents as reference materials or response checklists was not observed. Analysis 1.1: This lack of use for the mentioned job aids may have been due to lack of knowledge about their existence, lack of understanding about content, or just forgetting once the action started. If these tools and aids remain independent documents that are not incorporated or referenced in contingency plans, it can be expected that they will not be fully utilized in an actual event. Recommendation 1.1.: Prior to the start of the 2010 cruise season in Alaska, the unified command (UC) should evaluate the need and usefulness of subject documents. If the UC agrees to the merit of the documents, then the format and information should be jointly updated and reviewed by responders annually. To the extent possible, the documents should be incorporated into existing contingency plans to “institutionalize” the information. If the documents have limited value to the UC, then they should be discontinued as “unified” documents, but may continue to be used and updated by individual agencies that find merit in them. ********** Observation 1.2.: During this exercise, there were initially two operation centers – an industry operations center in Seattle and the USCG center in Juneau. Both locations were notified directly from the simulated ship. Once the situation was communicated and the severity understood, the community of Ketchikan was notified and an emergency operations center was established at the Ted Ferry Civic Center. There appeared to be some confusion about who was in charge when all 3 locations were activated and before the members of the unified command had assembled in Ketchikan. Analysis 1.2: Personnel assigned as members of the UC are often the personnel with the least amount of time working with one another, and may act independently. The intent of the documents discussed in Observation 1.1 was to provide sample priorities, objectives, and decisions/directives and check lists for coordinated initial actions to assist the UC in organizing itself and their required response structure. With multiple response centers and sites, the challenges for the response organization are to: • Avoid adding duplicate layers of command and control with corresponding 19 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 duplication of effort. • Ensure that critical information is communicated to maintain an accurate common operational picture. • Ensure that response efforts directed from the multiple centers is not counterproductive. • For example, there appeared to be extensive effort in the Ketchikan EOC to attempt to track passengers and crew as they moved from the ship to lifeboat to rescue vessel. The same tracking was also being done in Juneau and Seattle. To avoid duplication of effort, tracking could have been carried out in the D17 command center only since the USCG has primary jurisdiction for the search and rescue phase of the event. Once the numbers in the rescue vessels were known, this information could then be transmitted to Ketchikan and Seattle so that they shared a common operational picture. Recommendation 1.2.: Given the assumption that multiple emergency response centers will be activated in the early stages of a mass rescue response, the Unified Command should pre-define roles for emergency operations centers that will be reviewed and updated annually. The “Multi-Agency Quick Start Guide” mentioned in Observation 1.1 attempts to fill this purpose, but may need more clarity and detail. Recommendation 1.2.1.: Whether or not pre-defined roles exist, all response partners must confirm their roles, responsibilities and coordination expectations early in the incident. Recommendation 1.2.2.: The unified command must, as soon as possible, determine, discuss and communicate to all response partners their joint priorities, objectives and directives for how the organization will manage the incident. Recommendation 1.2.3.: It is recommended that a unified work group investigate options for command organizational structure during the early stages of a response with remotely located unified commanders and also identify additional training or job aids that may be required. ********** Observation 1.3.: In this exercise, Customs and Border Protection (CBP) reported that the ICS 201 document proved to be an excellent situational briefing tool to superiors at the area office. However, it was not clear where or which agency was responsible for development and distribution of the “master” 201. Analysis 1.3.: If each location generates a separate 201, the potential for conflicting information is high. Maintaining a common operational picture at three geographically separated locations requires adequate communication tools and capabilities, and agreement on the critical information that must be shared, who is responsible to collect and verify the information, and if possible, the format for data collection. The 201 provides a common format for collection and display of information while in the emergency response phase. 20 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 Recommendation 1.3.: Until the unified command transitions to a common location, response partners should agree on preparation and distribution of the 201 for maintaining situational awareness. ********** Observation 1.4.: With initial operations conducted from geographically separated command centers, the rapid and accurate exchange of information between sites is critical. Current contingency plans list one or two key emergency contact numbers for each agency. During this exercise, the extended use of these limited incoming lines, or utilization of a central switch board operator initially slowed the flow of rapidly changing information Analysis 1.4.: To improve and facilitate the flow of information, each agency/organization must quickly distribute an accurate communications (telephone/cell/email) plan to all their response partners at each location. This allows direct contact between responders at similar levels in the organization. Additionally, to aid the exchange of information, especially manifests and other intensive information, continued investigation into the use of a common readily available web based technology is recommended. This web based technology use is a recommendation from past exercises and events, but remains an issue in part due to the inability to agree and select a common application and concerns about security of systems. Recommendation 1.4.: The response organization must rapidly distribute a communications plan for their location to all response partners. To the extent possible, incoming calls should by-pass switch board operators or other central operator. Recommendation 1.4.1.: The unified command should continue efforts to identify and utilize readily available technology to facilitate the exchange of information. ********** Observation 1.5.: CBP reported that participation in the Ketchikan EOC was essential to quickly identify medically evacuated crew and communicate their priorities to the UC and actively support the operations at the landing site and reception centers. However, CBP found their integration into the EOC to be difficult with no clear reporting points or direction. There was no observed check in procedures or situation brief provided upon reporting, which likely added to the confusion. Other agencies likely experienced similar benefits and conflicts. Analysis 1.5.: An exercise artificiality was the compressed time for the activation of the EOC in Ketchikan, which occurred much faster than in a real event. This time compression may have resulted in some of the confusion, but not all. An organizational flow chart must be developed and communicated quickly, and key personnel easily identified by the use of vests or other method. A check in process that provides a situational brief and command review for all agencies and personnel reporting should be part of the process for operation of an incident command post. Recommendation 1.5.: A priority for the UC should be to develop and amend as 21 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 required an organization chart and implement a check in process that clarifies operations within the command post. Training should be provided as required. ********** Observation 1.6.: The use of liaison officers at the industry EOC and USCG Operations Center facilitated the flow if information and communications between the locations. Analysis 1.6: The exchange of liaison officers is a valuable tool for improving communications between locations. Liaison officers understand how their organizations operate, know the unique terminology, understand what information is often critical, and provide an on site “go to” point for clarification or advice. Experienced USCG personnel are locally available at each cruise line corporate location, and authorized ship agents are locally available at all Alaska cruise ship ports. Some ship agents also have clearance for access to controlled spaces within the USCG command centers. Recommendation 1.6.: The use of liaison officers to improve the flow of communications at industry and USCG command centers should be continued and encouraged as a “best practice”. Training should be provided as required. ********** Observation 1.7.: At the EOC in Ketchikan, a qualified ICS ‘coach” was provided to assist the unified command with implementing the ICS process and provide training and guidance to staff members. Analysis 1.7.: Often, especially in exercises, personnel with minimal real world ICS experience are assigned to the exercise organization. The role of the ICS coach is to help players with the transition from the ICS classroom theory to real time application. A coach adds tremendous training value and re-enforces the benefits of ICS because it enables the less experienced personnel to succeed. The coach is focused solely on making the ICS process smoother for the players. This is a benefit for both industry and government emergency operations centers. Recommendation 1.7.: The use of experienced ICS coaches in both exercises and real world events should be considered a best practice and highly encouraged. ********** Observation 1.8.: Many agencies and organizations were activated and assigned to field locations to support the landing and care of the evacuees. However, there was never a brief or explanation provided at each site to clarify action plans, priorities, check in procedures, expectations, chain of command or other operational information. As a result, there was confusion initially. Analysis 1.8.: Several different organizations mobilized during this event. Many had little to no experience working together and had a limited understanding of each others responsibilities or expectations. Without an on site incident brief prior to the start of operations, everyone proceeded to carry out their mission without an understanding of the other functions that were also being conducted simultaneously. These missions included site preparation and security, site operational management, medical triage and transport, 22 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 evacuee accountability, evacuee transport, evacuee sheltering and care, media management, etc. Recommendations 1.8.: An operations brief should be provided at each operational site prior to the start of activity. The brief should be sufficient to enable the various organizations to meet agency responsibilities as well as UC response priorities. ********** Additional Objective 1 Comments: • Unified Command needed to be established earlier to provide direction and priorities. • Establish meeting schedule early. • A requisition flow chart should be developed and posted to reduce confusion and improve the ordering of materials and services. • Establish a unit for Volunteer Coordination. 23 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 OBJECTIVE 2: Coordinate rescue and assistance action plans for the evacuation and transportation of evacuees from the (simulated) incident site to a designated landing/recovery sites. Capability: Search and Rescue Summary: This objective and capability was performed successfully but with some challenges noted. The exercise provided an opportunity for response partners to gain experience, team build and identify areas for improvement. The USCG Juneau Rescue and Coordination Center (JRCC) supported by Sector Juneau Command Center personnel coordinated information and actions with the ship and company emergency operations center to develop a rescue plan using real time assets. The plan included using the ship’s life boats in combination with Ketchikan based small passenger vessels and Alaska Marine Highway vessels to transport evacuees to Ketchikan. ********** Figures 5: Small boat from Canadian Coast Guard Cutter TANU simulates recovery and transport of ALASKA CRUISER crew members. Observation 2.1.: Several hours had passed before USCGC NAUSHON was formally appointed On Scene Coordinator (OSC) by the SAR Mission Coordinator (SMC). Analysis 2.1.: Having an on scene coordinator appointed early is crucial for the success of the rescue effort and the accountability of passengers. During day one there appeared to be confusion between the cruise ship master and the OSC about their respective responsibilities with regards to the rescue plan. The presence of a Sector Juneau representative on the simulated bridge of the cruise ship also added to the confusion as the master assumed this person was responsible for the direction of on scene rescue operations. As a result, resources on scene, both ships and aircraft, were put in “holding patterns” and left trying to determine what the rescue plan was and who they should take direction from. Once this confusion was settled and the OSC’s role clarified, the Commanding Officer of the USCGC NAUSHON did an excellent job of directing resources and tracking passengers given the support that would have actually been available on the cutter. Recommendation 2.1.: The SMC must designate an OSC as early as possible and communicate this appointment to all involved resources. Once appointed, the OSC and master of the distressed vessel must communicate on expectations, duties and 24 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 responsibilities, and critical information that must be shared to develop and execute an Evacuation/Rescue Plan. Recommendation 2.1.2.: USCGD17 should consider providing annual training to all District cutters on the responsibilities of an OSC and the unique actions to consider during a mass rescue operation. ********** Observation 2.2.: The response efforts and on scene plans developed by the master and the OSC were complicated on several occasions when the Command Center and Seattle EOC tried to direct or change the on scene plan without appropriate consultation. Analysis 2.2.: On scene personnel have the best picture of on scene conditions and are usually best positioned to develop action plans. That said, it is also important for on scene intentions to be communicated early to the USCG and company management for additional considerations and recommendations that may have been over looked in the heat of the moment. Keeping all levels informed to the maximum extent possible should reduce or eliminate remote tasking that may be based on old information. Recommendation 2.2.: On Scene responders must communicate response plans and conditions to shore side command centers to the maximum extent possible. ********** Observation 2.3.: The OSC workload and information management for an incident of this magnitude is significant and may overwhelm a single resource. Analysis 2.3.: It is likely that in a real world event of this magnitude, the OSC may be overwhelmed and some OSC duties may need to be delegated to other on scene assets or managed by the SMC. To make this determination requires thoughtful evaluation by the OSC and SMC of capabilities and on scene demands. Once the OSC span of control exceeds the ability to properly manage, support must be provided. Recommendation 2.3.: For incidents with significant rescue resources on scene and a large demand for information management, USCG SMC and OSC should consider delegation and assignment of duties. ********** Observation 2.4.: In this incident, cruise ship Berth 3 was designated as the designated landing site. This was a floating berth with moorage for multiple vessels. Ramps and/or stairs were available. The site chosen for the exercise appeared more than adequate for the safe movement of passengers off the vessels. Local emergency crews did an excellent job of securing the site, setting up triage areas, and managing transportation flow. Analysis 2.4.: The choice and set up of a suitable vessel landing site is a critical component for the smooth flow and accountability of passengers as they move from the rescue vessels to reception and medical facilities. Responders should have options available for safely offloading evacuees from rescue craft with varying deck heights, 25 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 procedures for offloading injured and or handicapped persons, and personnel to provide immediate assistance to evacuees who become faint or weak after offloading. Recommendation 2.4.: The lay out and procedures utilized at Berth 3 should be documented and included in the city emergency response plan to enable repeated performance and rapid set up. ********** Observation 2.5.: One weak point in the landing site organization was the failure to appoint a “manager” with the authority of the UC to supervise landing site operations and resolve conflicts, including designation of berths and controlling the flow of vessels coming alongside. Although an industry official attempted to take control, he was wearing nothing that would distinguish him from the general public, and was likely not familiar with the plans established by the community on what had been set up. Analysis 2.5.: With local, state, federal, industry, and NGOs all having a need to be at the landing site, the opportunity for confusion and conflict is real, and was observed in this exercise. The role of the landing site manager is to ensure that operations run smoothly, that all responder actions are coordinated, and conflicts are resolved in accordance with UC priorities and objectives. Ideally, the manager should have jurisdiction over the landing site, be known and have developed working relationships with the majority of responders, and have an understanding of mass rescue and crowd control concerns. Recommendation 2.5.: For each designated landing site, a qualified manager should be appointed and clearly identified by use of vest or similar identifier. The manager should have familiarity with the landing site and capabilities, knowledge of the responsibilities and jurisdictions of involved agencies, and an understanding of the operations plan. Recommendation 2.5.1.: Prior the start of landing site operations, the site manager should conduct a briefing meeting with all involved agencies at the site to clarify operations, check in procedures, safety, expectations, communications, conflict resolution, and issues. Recommendation 2.5.2.: A sample landing site organization chart and checklist should be developed and included in emergency response plans. ********** Observation 2.6.: There was no communications plan established for landing site operations. Analysis 2.6.: A landing site communications plan is required to enable rescue vessels to report and receive assignments directly from on scene personnel, and for landing site operations to report status and resource requests to the UC. The more direct the pathway, the clearer and more accurate the exchange of information. 26 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 Recommendation 2.6.: Include landing site operations in development of incident communications planning. ********** Observation 2.7.: One particular observation regarding the plan for offloading vessels was the amount of time that vessels were being asked to stand off and wait to come alongside. The theory was that this would allow better control of the passengers coming ashore. This reasoning however was not transmitted to the rescue vessels which caused some frustration when it was clear that dock space was available. Analysis 2.7.: Asking vessels to hold off, or to have evacuees remain on board may work fine if the rescue craft is comfortable and capable of supporting the needs of the rescued people and there are no injured on board. However, if injured people are on board or the craft is a cramped rescue boat with 150 seasick, tired, cold, hungry people who need bathroom facilities, any delay will raise the anxiety level of already stressed passengers and make shore side control more difficult. This is the type of situation that the landing site manager must manage based on the current conditions, communications from the rescue craft, the priorities of the UC, recommendations of agencies on scene. Recommendation 2.7.: As part of an updated Landing Site Job Aid, considerations and priorities for the landing of rescue craft should be provided. ********** Observation 2.8.: Although there was a landing site job aid provided, some of the key recommendations were missed. Analysis 2.8.: Establishing and operating landing sites during mass rescue operations is not a common activity and experience will be hard to develop. The use of job aids, checklist, and other tools provides a valuable reminder of required actions. The response community is encouraged to develop, update, train and distribute job aids as required to support operations. Recommendation 2.8.: A joint work group should review, update, and distribute the landing site job aid currently available. ********** Observation 2.9.: As part of the exercise, cruise line logistic specialists identified contract aircraft to fly passengers from Ketchikan to Seattle. There was discussion about loading required provisions and or medical equipment on these planes prior to dispatching them to Ketchikan. Analysis 2.9.: Although this observation concerns charter aircraft, it can also apply to rescue vessels dispatched to the scene. If known materials and supplies (or materials likely to be needed) are readily available and time permits, then responders should consider loading these supplies on rescue resources prior to dispatching. Examples for supplies that may be of value on rescue boats include water, food, blankets, and basic medical supplies. For aircraft, supplies to consider are those that are not available locally 27 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 or require re-supply, materials for special needs populations, additional clothing and toiletries, etc. Recommendation 2.9.: If time permits, responders should consider the value of loading rescue units with materials and supplies that are required, or likely to be required, on scene. Recommendation 2.9.1.: A list of potential supplies to consider should be included in MRO response plans. ********** Observation 2.9.10.: Separation of all crew from the passengers limits the use of crew members in supporting the needs of passengers as support for handicapped or elderly passengers, for use in the accountability process, for staffing at check in locations, and other assignments to support personnel shortfalls shore side. Crew members who are in good health and who normally interact with passengers should be made available to assist in the shore side response efforts. A previous exercise in the Caribbean included the use of the ship’s hotel staff to support the local community with landing site and reception center operations. This “self-help” activity proved beneficial as many of the passengers and crew were familiar with these people. Analysis 2.9.10.: Using selected crew members to support the local community with shore side operations is a valuable recommendation, and the most readily available source for manpower, especially in the smaller Alaskan port communities. Prior to assigning crew, coordination must occur with CBP to ensure CBP requirements are met to properly process the foreign crew members. Prior to assignment is the response, crew members must receive a briefing to explain their duties, reporting requirements and other information. Recommendation 2.9.10.: The use of crew members, after proper clearance by CBP, to assist shore side evacuee care and support actions should be considered a best practice. 28 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 OBJECTIVE 3: Account for passengers and crew with 100% accuracy by the end of the exercise. Capabilities: Search and Rescue and Accountability of Evacuees Summary: This objective and related capabilities were performed successfully but with some challenges noted. Overall, exercise participants did an excellent job of accounting for the evacuees. Although 100% accountability was not possible due to a design failure with the exercise, the process established by the industry players did identify specific evacuees that were missing and response efforts continued to locate the missing. At the start of Day 2, players were provided of list of evacuees that had been landed and accounted, and a second list of 720 evacuees that had not arrived. About 160 real life volunteers were used to simulate 720 evacuees. For reasons that remain unclear, approximately 60 passenger name cards that were injected into the system were lost. They may have been lost because the individual volunteer that was assigned the cards forgot or failed to turn them in, or the cards were left on the bus, or any other number of reasons. ********** Observation 3.1.: During both evacuation and transit phases there was significant concern about an exact count of individuals on board each vessel, and a break down of the number in terms of passengers, crew, and nationalities. Given the small crews on board some of the rescue vessels, getting an accurate count, let alone a breakdown of the count, is going to be challenging. Analysis 3.1.: Accurate numbers are critical. A break down of the evacuees into categories may be difficult for on scene rescue resources to accomplish, especially early in a response. In fact, at one point, there were requests for breakdowns of passengers and crew, as well as how many were U.S. citizens and how many were foreign nationals. On many rescue craft, there will not be the personnel resources available to accomplish this task. Once the situations stabilizes and the vessels are enroute to shore, then a further breakdown may be possible, especially if evacuated crew members support the effort. The evacuation plan for the cruise lines is to have ship staff accompany passengers aboard every life raft, boat and rescue ship. These crew members can be assigned to produce an accounting of passengers and crew on their unit while on the way to shore. This step would allow for an accounting of passengers and crew as they reached shore to proceed much more quickly, but once ashore, the evacuees may not stay together as a group. A life boat holds 150 people while a bus holds 50 or less. Before responders demand detailed information from rescue resources, there must be a plan for how the information will be integrated once ashore. 29 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 Recommendation 3.1.: Requests for passenger counts from the scene should be kept to a minimum to avoid overloading the on scene units with information requests. Recommendation 3.12.: If a breakdown in numbers is important this should be defined in response plans to ensure it is clear why those numbers are important, and what the order of priority should be. Possible breakdown: • Number of passengers and crew evacuated from vessel – this would be important in determining whether all the passengers are off the vessel and how many crew remain. • Total number on each rescue vessel and how many require medical assistance – these numbers are important to determine if everyone evacuated is accounted for and what support services will be required when the rescue vessel reaches port. • All remaining breakdowns, including reconciling manifest with passengers and crew, are conducted once they are landed ashore ********** Observation 3.2.: As part of the second day of the exercise there was an opportunity for the Canadian Coast Guard (CCG) to test CASTRACK, a casualty tracking system that is currently under development. Prior to the exercise, the crew of the CCGS TANU was provided training in the use of the system. Analysis 3.2.: During the exercise the TANU recovered 39 people from a life raft and used the CASTRACK system to track/account for the survivors. The system appeared to work well particularly for confirming the initial count. Both USCG and Holland America representatives expressed interest in the system. Recommendations to improve the CASTRACK system provided by the crew were primarily concerned with the size of the recording boxes on the sheet and the type of pens used. Recommendation 3.2.: USCG should follow the development of the CCG CASTRACK system and evaluate its use. ********** Observation 3.3.: Industry teams conducted the majority of their accountability process when personnel were loaded on buses. Buses were held at the loading site until accountability was completed. Since there is space for only a limited number of buses, some evacuees were forced to stand around and wait until this “bottle neck” was corrected. Analysis 3.3.: The weather during the exercise was warm sunshine and mild winds. Once evacuees were landed ashore, it was comfortable for them to wait to be loaded on to buses. However, if a more normal wind, rain and cool weather pattern was present, having elderly, seasick, or tired evacuees stand around waiting for transportation would not be acceptable. It may be possible to control the arrival of rescue boats if they are 30 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 comfortable, but a cramped life boat with 150 people will need to be landed and offloaded without delay. Requiring evacuees to then stand around in poor weather will be difficult. If accountability will be completed onboard buses, a process should be considered that permits bused to be quickly loaded at the landing site, moved to a secure marshalling area where the accountability process can be completed. This would eliminate a dockside bottle neck. Bottle necks have the potential to occur at many points along the route. To the maximum extent possible, the most likely “bottle necks” should be identified in response plans and managed to mitigate effects. Recommendation 3.3.: Response plans and procedures should be evaluated to identify and eliminate or manage all anticipated “bottlenecks” that force evacuees to stand in line. ********** Observation 3.4.: Many agencies used this exercise as an opportunity to evaluate internal procedures for tracking. Separate systems were being evaluated including medical tracking (wrist bands), the previously mentioned CCG CAS TRACK system, a demonstration of Seatags Safety System for accountability, and the manual system that is currently used. The use of all these different systems, combined with the exercise name cards used to simulate passengers and crew was confusing. Analysis 3.4.: There are several options, both manual and technical, that may be suitable to support an accountability process. No matter which system is used, it should be known and briefed to all response partners. Ideally, all response partners should agree to a standard method and put it into contingency plans. Past work groups developed a boiler plate “Standard Accountability Process” which should be reviewed, evaluated and updated as required. Recommendation 3.4.: Only one accountability process should be employed for an incident. This process should be briefed and understood by all responders to avoid confusion and align expectations. Figures 6: Ketchikan High School students volunteered to role play evacuees. ********** Observation 3.5.: Exercise Design. Due to a loss of name cards that represented evacuees, 100% accountability was not possible. Analysis 3.5.: See bulleted below. • Use of Cards to Represent Evacuees: The recruitment of a sufficiently high number of volunteers to role play evacuees is difficult, especially in small 31 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 communities. This lack of real people required the use of name cards or tags to simulate a higher number of evacuees. Due to loss of cards that represented evacuees, achievement of 100% accountability was not possible. • During the 2007 MRO exercise in the Caribbean, ship’s crew were directly involved as exercise players. In the Alaska MRO 2009 exercise, no ship was in port, so real ship staffs were not used in exercise play. Future exercises should include either real or role players to accomplish duties that would normally be completed. Recommendations 3.5.: 1. The use of name tags/cards to represent individuals for tracking purposes presents problems. If possible, the best solution is to use real people. One volunteer represents one evacuee. 2. Include Ship Personnel in Execution. In an actual event, ship personnel would, to the extent possible, be directly involved in the care and accountability of evacuees, and would support tallying numbers of rescue boats. During this exercise, conflicts arose when the rescue vessels operated by Allen Marine were unable to provide accurate numbers of evacuees on board. This was the result of the short amount of time to report; the confusion represented how the “cards” factored into the total count, and the lack of any shipboard role players to support this activity. 3. If cards are used, have each person represent a consistent number of evacuees. Example: One volunteer represents five evacuees. Consistency will benefit exercise players. They know what to expect. 4. Develop a means to track and collate the names of the volunteers with the names of the evacuees they represent. If names come up short, this tracking system will help isolate the source of the problem. 5. If name cards are used, they should be placed on a lanyard around the neck of the volunteers to prevent loss. The total number of evacuees represented by the singe volunteer should be clearly visible to exercise players. ********** Additional Objective 3 comments: • There was no accountability section established at the reception center. For this exercise, accountability was completed on the buses, but an accountability presence at the center is recommended to track down discrepancies. 32 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 • There was no check in and check out procedure established at the center. The accountability group managed the overall accountability, but once evacuees left the bus and entered the center, there was not method to track them from there. 33 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 OBJECTIVE 4: Establish and operate incident facilities that include the Industry Command Centers, Coast Guard Search and Rescue Command Centers, and the Unified Command/Incident Command Post in the Ketchikan. Capability: Unified Command (UC) organization and communication. Summary: • This objective and capability was performed successfully but with some challenges noted. As in a real event, the three locations experienced some start up problems including wrong telephone numbers, slow information sharing, and organizational confusion. As the exercise continued, these problems diminished and by the second day had been mainly resolved. • The USCG JRCC and Sector Juneau command center are staffed 24/7. Both locations are secure spaces and admittance requires a security clearance. Sector Juneau established a non-secure location in close proximity to the secure command centers for response partners to work and assist in planning. Security Guards screen all entrants to the Federal Building, and secure USCG spaces are behind locked doors. Cells phones are prohibited in the secure spaces. • The industry EOC in Seattle is full time center and available on immediate notice. The location is designed primarily to support company personnel, but space is available to support a limited number of liaison and other support personnel. Access to the building is easily controlled at the building entrance, and all spaces are behind locked doors. Key cards are required for access. • The City and Borough of Ketchikan EOC was located in the Ted Ferry Civic Center. It is not a permanent location and must be set up. The facility has approximately 50 direct access telephone lines and telephone that can be activated on short notice, wireless internet, and sufficient tables, chairs and other support items to be operational with in a short time period. Access to the building and EOC spaces must be controlled by response organization. ********** Observation 4.1.: A functional check in process was not established at the Ketchikan EOC. Check in was just a sign in process. This permitted free access to the EOC, and prevented new personnel from receiving an incoming incident brief. Additionally, there was also no responder check in process established at the landing site or reception center. This also allowed responders access at these sites without an understanding of the chain of command, safety brief or operational requirements. Analysis 4.1.: The response organization needs to limit access to EOC and field sites to assigned personnel. Often this is accomplished by a private security firm at access points. 34 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 People with no purpose in the EOC or field sites add to the confusion and noise and slow the response organization. Part of the check in process is to receive assignment and an initial incident briefing, including a safety brief. The check in process should be robust and in place early. If check in is an after thought, significant issues may ensue. Recommendation 4.1.: Establish a site security plan and check in procedure early in the response to limit access to work spaces, and ensure personnel and resources are tracked. Figure 7: Emergency Operations Center established at the Ted Ferry Civic Center in Ketchikan, AK. ********** Observation 4.2.: The Ketchikan EOC is not a permanent facility and must be set up for each incident. Analysis 4.2.: When an EOC is required - it is required quickly. To speed the establishment and set up of a non-permanent EOC, plans are required that detail tasking and assignments, layout of spaces, list of required supplies and sources, and communication numbers if available. Regular set up practice, as part of exercises or as stand along training, must be conducted. Recommendation 4.2.: As part of the Ketchikan Emergency Response Plan, a detailed EOC set up and operational plan should be developed. The set up of the EOC as used in this exercise should provide a good foundation for future EOC establishments. ********** Observation 4.3.: The EOC in Ketchikan was staffed by multiple organizations and individuals, each with varying degrees of ICS training and experience. As a result, there was a fairly steep learning curve on the use of ICS to manage the response. As the incident progressed on the second day, the UC became more proficient and provided better direction and tasking. Analysis 4.3.: OCS requires training, practice, and real incident application. With large incidents uncommon, it if often difficult for responders to gain interagency ICS experience. Exercises often provide the best tool to build a base of experience for the widest pool of responders. To the extent time and resources are available, responders should attempt to participate in as many different exercises, no matter the scenario, to gain experience in ICS use and interagency understanding. Recommendation 4.3.: Continue to conduct regular interagency ICS training and exercises to expand the knowledge and experience of responders. ********** 35 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 Observation 4.4.: The following observations indicate the need for additional interagency ICS training: • Air Operations branch not established. • Confusion of the use of form 213RR. • Infrequent and out dated situation updates. Players largely uninformed the first day due to lack of timely and organized meetings and briefing. • Lack of EOC and field check in and security process. • Safety briefs slow to be initiated. Analysis 4.4.: ICS requires training and practice. Recommendation 4.4.: Responders should continue to conduct interagency ICS training and response workshops to maintain a minimum level of ICS experience and skills. 36 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 OBJECTIVE 5: Implementation of a shore-side support plan for evacuees that including triage and medical services, local transportation, sheltering and personal care. Capability: Shore side support and care of evacuees. Summary: This objective and capability was performed successfully but with some challenges noted. Evacuees were properly provided medical care, shelter, water, food, and transportation. The landing site set up was efficient, and well designed. The area was secured and cordoned off permitting good site control. Medical triage and support was well coordinated and managed. Operations were safe. Transportation was coordinated and adequate to meet the needs of the incident. The reception center was adequate for the incident as exercised, but additional training to improve coordination and communication between all involved agencies at the center is recommended. ********** Observation 5.1.: Triage and emergency medical operations on the dock were coordinated by the Ketchikan Fire Department. The EMS established included shelter tents, motorized carts for moving stretcher victims up the dock, ambulance staging areas, special needs coordination and required supplies. The community is well prepared and trained to handle mass casualties that may be expected in their community. However, in a maritime mass rescue scenario with 2,500 or greater evacuees coming ashore in short order, additional support would be need. Analysis 5.1.: Mass rescue operations with significant mass casualties will quickly over whelm Alaska port communities, especially in SE Alaska. Additional support will be required. Medical personnel from the affected ship and passengers with medical skills that were aboard the ship will likely be required to support EMS operations. Crew members and other passengers may be needed to assist handicapped or fatigued evacuees, assist with accountability process, and provide manpower at various locations that will be in short supply. Figures 8: Ketchikan Fire and Harbor Departments prepare landing site facilities. Recommendation 5.1.: Joint planning efforts are recommended to explore the options for identifying and implementing crew and passengers in the shore side support operations. ********** Observation 5.2.: The majority of passengers interviewed were well informed of what was happening to them. A majority of them indicated they were given a brief on the bus and they understood the importance of accountability and purpose for the reception center. Once at the 37 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 reception center however, there was no further information provided. Analysis 5.2.: Providing evacuees with information is an important tool for reducing anxiety and encouraging cooperation. To the extent possible, information and explanations should be provided at the soonest opportunity. Additionally, information centers established at reception centers are encouraged to provide a one stop location for updates on travel schedules, luggage issues, locations of family, etc. If the response organization does not provide the best source of information, rumors and opinion will fill the void. Recommendation 5.2.: Establishing information centers for evacuees at reception facilities to provide current information should be included in response plans, and is recommended as a best practice. ********** Observation 5.3.: A number of agencies working at the reception center mentioned the need for better inter-agency planning. In general, there was a lack of understanding on the responsibilities and requirements for each agency, and how to best coordinate the requirements to meet the common goals of evacuee accountability, care and support. This lack of understanding led to some heated discussion concerning priorities for work to be completed. Analysis 5.3.: At the MRO reception center, local, state, federal, industry and volunteers representatives will all have requirements and mandates. Since MRO reception centers are not common operations, the understanding of the various tasks that will be occurring and how they are best coordinated will not be common knowledge. Additional reception center planning is required to identify all agencies/organizations involved, their missions and responsibilities, and procedures for coordination and communications. Recommendation 5.3.: An integrated reception center operations plan should be jointly developed. Recommendation 5.3.1.: Conduct inter-agency reception center operational training table top exercises to test and evaluate the plan. ********** Observation 5.4.: A reception center manager was appointed, but was not easily identified, and not sufficiently trained to understand all the activities that were simultaneously occurring at the center. As a result, when conflicts arose over priorities there was no single authority to decide the issue in accordance with UC directives. Analysis 5.4.: A reception center site manager is an important appointment. This individual ideally should have jurisdiction over the facility and an understanding of the purpose and operations of the center. Similar to a landing site manager, the reception center manager should know and have an understanding of the requirements for all the agencies that will be present. To be successful, additional training and job aids/check lists are required for site managers. Recommendation 5.4.: Improve reception center operations by improving existing job aids and developing check lists for site managers. Training and table top exercises will be required to 38 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 evaluate the job aids and to provide experience. ********** Observation 5.5.: A need was identified for similar information on evacuees from agencies at all levels in the response, but there was not common form for collecting and sharing this information. Analysis 5.5.: In a large response, evacuees may be checked in at several locations. A common form that captures the basic information needed by the majority of response agencies would smooth the exchange of information. Determining the “core” information to collect from evacuees that satisfies the needs for the majority of response organizations is the critical first step in this process. Once developed, this form could be used by organizations that arrive at different times to initiate work without having to re-interview every evacuee to collect information. Recommendation 5.5.: A joint work group should de assigned to identify the core information required from every evacuee and develop a draft form for review by the Unified Command. Figures 9: Emergency medical services established at landing site. ********** Figures 10: Ketchikan General Hospital and Ketchikan Indian Community Clinic preparing to receive patients transported from the landing site. Additional Objective 5 comments: • Include bus and transportation routes in shore side response planning. Place police for traffic control at anticipated “bottle necks”. • Supply buses with motion sickness bags, water, nourishment, blankets, basic toiletries, etc if evacuees will be confined to held on buses due to longer transits, accountability processing or other purpose. 39 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 • Develop a basic reception center safety plan to speed the development of an incident specific plan. • Increase signage at center to improve movement and identify locations – information center, rest rooms, medical support, food, etc. 40 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 OBJECTIVE 6: Development of joint pollution response, environmental protection and other plans to address the scenario consequences. Capability: Marine Environmental Protection (MEP). Summary: This objective was successfully demonstrated and performed without challenges. This objective was included to illustrate the value of using ICS to manage a complicated scenario with several functions occurring nearly simultaneously. The responders that managed pollution response, environmental and wildlife protection, salvage and non-SAR missions consisted of a group of experienced, well trained responders. As a result, pollution response, environmental protection, salvage, and the other consequence management issues were well executed during this exercise. As a result of this high level of experience in the core group, there were no significant issues identified. The work of the Environmental Unit was particularly noteworthy. ********** Observation 6.1.: The majority of comments remarked that the small problems encountered were the result of lack of ICS familiarity by some of the exercise players. Most of the issues significantly diminished or disappeared by the second day. Analysis 6.1.: This exercise enabled a wide range of new people to work together. Out of town responders integrated with the Alaskan based responders. As with any new grouping of people, there will be start up confusion due to varying degrees of training, experience, and group dynamics. The beauty of ICS is that is provides the common ground for the team to build upon. Recommendation 6.1.: All responders are encouraged to continue participating in a wide variety of exercises to gain experience and exposure to response partners. ********** 41 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 OBJECTIVE 7: Establish and operate a joint “media plan” for response to an elevated public affairs demand to the given scenario. Capability: Unified Command (UC) organization and communication. Summary: This objective and capability was performed successfully but with some challenges noted. Lack of injects from exercise control limited level of media play, especially on the first day. As in a real event, agencies released independent media releases initially providing the basic incident facts. The unified command and their public affairs staffs each recognized the need and value for establishing a unified media organization. By late day one, a joint information center (JIC) was established in Ketchikan. ********** Observation 7.1.: No formal media and information sharing plan was developed. Information concerning the lone fatality was shared with media that the UC was unaware. Analysis 7.1.: The lack of a media plan may be the result of the exercise ending before the JIC had the opportunity to complete the plan. The UC must stress the importance of a joint public affairs process and create a media plan early. This plan needs to provide the UC rules and requirements for media relations, including press release authority, interview process, media access and escorts, release of identification of sensitive information, and any other specific directions and requirements of the UC. The early release of NOK information to the media may have been prevented if a media plan was in place. Recommendation 7.1.: To facilitate the development of joint media operations during an event, a template for a joint media operations plan is recommended for inclusion into contingency plans. ********** Observation 7.2.: At the landing site and reception center, no media staging areas were provided. Analysis 7.2.: Media representatives will go to the site that provides the most activity. In a MRO event, that will be the landing sites and reception centers where evacuees are available to interview and the 30 seconds of video is best taken. The UC should plan to provide controlled media access and escorts at key locations. Recommendation 7.2.: Include media staging areas in the development of landing site and reception center plans. ********** Observation 7.3.: Joint media operations are not a common activity for many media staffs and JIC operations, procedures and integration experience may vary widely. Recommendation 7.3.: Increased training and JIC specific exercises are recommended to increase the JIC experience public affairs staffs. 42 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 OBJECTIVE 8: Establish timely communications and information exchange between the ship, industry EOC, response agencies, and impacted port community. Capability: Search and Rescue (SAR). Unified Command (UC) organization and communication. SUMMARY: This objective and related capabilities were successfully performed but with some challenges noted. Response partners were notified quickly, and recall of their internal staffs occurred without any significant problems. As in a real event, the process for inter-agency communications and information exchange improved over time, especially as the UC established itself in Ketchikan, and their staffs integrated in the ICS structure. ********** Observation 8.1.: With the exception of the initial telephone calls, telephone lines got jammed very quickly. Cell phones were critical to maintain the flow of communications. Analysis 8.1.: Current contingency plans commonly list only one or two emergency contact numbers for initial reporting of incidents. Until other numbers and contact points are provided, these are the only telephone numbers available for response partners to call and these limited lines will be insufficient to handle the crush of calls that can be expected. Similarly, if calls are forwarded to a “switch board”, incoming call will quickly overwhelm the operator. Recommendation 8.1.: To speed the flow of information, response partners must rapidly develop and distribute a communications plan (telephone/cell/email/web) to all response partners. This allows direct contact between responders at similar levels in the organization. ********** Observation 8.2.: The number of telephone lines available in a command post location may be a limiting factor, and the installation of additional lines may not be practical in the time available. Analysis 8.2.: Alternative communication methods and use of technology should be explored, especially for exchange of large amounts of data (manifests, damage surveys, etc). The use of instant chat and other web based tools should continue to be investigated to improve the speed and accuracy of data sharing. Recommendation 8.2.: The use of instant chat and other web based tools should continue to be investigated to improve the speed and accuracy of data sharing. ********** Observation 8.3.: On scene, the USCG appointed the USCGC NAUSHON as the on scene coordinator to support the master with the evacuation and rescue of evacuees and manage on scene rescue units. Additionally, Sector Juneau dispatched personnel to the cruise ship to evaluate the on board condition of the vessel and support master. This caused some initial confusion for the master since it was not clear who was in charge on scene for the USCG. As a result, some information that should have been shared with the OSC was not, or was shared late. 43 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 Analysis 8.3.: This is a common situation. USCG personnel will be present on the ship assisting the master with the emergency, and also on scene aboard on USCG vessels serving as OSC managing rescue units. The function of each, the chain of command and the preferred flow of information must be clarified early on between the ship master and USCG personnel. All units must ensure information is shared on scene, either by the use of VHF to allow on scene units to monitor communications, or passing all information through the OSC. Recommendation 8.3.: USCG units and personnel on scene must clarify the chain of command and communication flow with the master of the ship early in a response, and develop a process to ensure all on scene units are keep informed. ********** Observation 8.4.: The ship and the company office maintained an open line to ensure immediate communication ability. This required a dedicated communicator at each end. Several comments expressed the concern that partners did not call each other enough. Analysis 8.4.: Maintaining an open line was recommended as a best practice at the 2004 Alaska MRO Workshop. If necessary, the USCG command center can also establish an open line to the company EOC and utilize a liaison officer to man the line and pass information. A three way open line between the ship, USCG and company EOC has been discussed but not implemented. As mentioned in earlier discussions, the use of liaison officers is a valuable tool to improve information exchange. Recommendation 8.4.: Continue to use the open line concept and liaison officers to facilitate information exchange. At future exercises, conduct a trail run using a 3 way open line to evaluate its effectiveness. ********** Observation 8.5.: It was unclear from the comments if the UC developed and distributed their decisions and directives, including critical information that must be immediately reported. Analysis 8.5.: It is important for the UC to meet in person or via teleconference early to determine how they will conduct business, including detailing what information is critical to them and reported immediately. Much of this type of information can be developed and included in response plans, and then modified for specific incidents. Recommendation 8.5.: A joint work group should develop sample UC decisions and directives that can be quickly amended for specific incidents. These types of management tool enable a quicker and smoother transition to UC, and provide early direction for staffs. ********** Observation 8.6.: Initial contact telephone numbers were incorrect. Analysis 8.6.: None Recommendation 8.6.: Annually, update, and test all emergency contact numbers. ********** Observation 8.7.: CBP officers were effectively able to communicate with all local law 44 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 enforcement agencies via service vehicles and hand held radios. Landing site operations identified the need to have Ketchikan Ports and Harbors internal frequency programmed into CBP radios. Analysis 8.7.: Local response agencies must be able to rapidly communicate in an emergency. In Ketchikan, the city and borough have been forward leaning and have the communication tools in place for inter-operability. If this does not exist, then providing agency specific radios to response partners may be required. Recommendation 8.7.: Local port communities should evaluate the ability for local responders to communicate in an emergency. As required, take action to improve inter-operability of communications. ********** Observation 8.8.: At the 2004 response workshop, a Communications Best Practices form was developed. Many of the recommendations were used during this exercise. Analysis 8.8.: Technology and procedures have likely changed since 2004. The Communication Best Practices document may require review and updating to reflect these changes. Recommendation 8.8.: A joint work group should review and update the Communications Best Practices document. ********** Observation 8.8.: Video conferencing is available and was utilized for communications between the USCG Juneau command center and industry Seattle EOC. Analysis 8.8.: Positive comments were received on the use of video conferencing. Although this tool had been available for along time, its use during exercises in Alaska has been limited. Recommendation 8.8.: Increased use of video conferencing in exercises should continue with the goal of identifying ways to improve the use of video conferencing. ********** Observation 8.8.: Although there was no security issue or classified information involved in this exercise, there was sensitive and personal information, especially the name of the fatality and critically injured passengers that was passed on VHF or unencrypted e-mail. Analysis 8.8.: The requirement for information security is one not commonly raised in exercises that do not involve terrorism or other security threat. But identifying and managing both classified and sensitive / personal information is an important function that should be included in response plans and addressed early in a response by the UC. As part of their initial decisions and directives, the UC should clarify the how sensitive / classified information will be shared, encryption or password protection requirements for email, use of secure telephone lines and other considerations should all be addressed. A sample communications plan for MRO incident may assist in the timely development of the incident communication plan. 45 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 Recommendation 8.8.: Identify the conditions for use of password protection, encryption, or procedures for passing sensitive or personal information over the internet and include in agency response plans and other response guidance. 46 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 OBJECTIVE 9: Establish an Emergency Call Center and web site to serve as a point of information for family and friends of guests and crewmembers sheltered in Ketchikan. Capability: Unified Command (UC) organization and communication. SUMMARY: This objective and capability was successfully performed with some challenges noted. An emergency call center was quickly established by the industry. This function is critical to reduce the incoming calls to industry, USCG, and community command centers or general offices. Family and friend calls have the potential to jam available telephone lines required by responders. The emergency call center must be rapidly activated and widely advertised. Most call center representatives were helpful and attentive to family member’s questions. All call center representatives were able to provide the callers with the toll-free number and website for additional updates and information regarding the incident. All of the call center representatives had accurate preliminary information regarding the incident. All of the call center representatives indicated that the family member would be contacted by another cruise line representative for additional follow-up. ********** Additional Objective 9 Comments: • This exercise was not able to replicate the volume and frequency of call that should be expected from the evacuation of a cruise ship evacuation • Discontinue routine cruise line music and advertising on the toll-free telephone number family members are directed to use. • Several of the call center representatives asked the caller if they had a booking number for their family member. If this is not something that family members would normally have, reconsider asking for this information. • Two call center representatives seemed to be on auto pilot. They did not give the appearance that they were listening to the questions being asked by the caller. These representatives simply read a summary update of the incident and included information about crew members when the call was from a passenger family member. • No calls were simulated from crew member families. Considerations should be given to how these calls will be handled given the language issues and call back difficulties. • Emergency call centers should have plans for access to language specialists as required. • None of the call representatives could answer questions regarding travel arrangements for family members who wanted to travel to the location where victims from the incident were being treated. 47 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 OBJECTIVE 10: Validate the Global Maritime Distress and Safety System (GMDSS) notification system. Capability: Search and Rescue (SAR) SUMMARY: This objective and capability was successfully performed but with some challenges noted. This objective was demonstrated by activating a GMDSS alert testing system aboard the Canadian Coast Guard ship TANU. The distress alerts included activation of the ship’s HF Digital Selective Calling and test EPIRB activation. Additionally, the TANU, while alongside the dock in Ketchikan, conducted tests using a prototype AIS Search and Rescue Transponder (SART). These units have built in GPS receiver and transmit position and beacon information to shipboard and shore based AIS receivers. CCGS TANU was extremely professional and tests performed simulated real events. ********** Observation 10.1.: CCGS TANU did not receive any confirmation of the DSC alert from ashore or from any other vessels that the signal was "accepted" or received as would have been expected. With no confirmation or acknowledgement from anyone after a few minutes, calls were made to COMSTA Kodiak and JRCC Victoria to verify that the alert had been received. Seventeen minutes later, TANU received confirmation over the phone that the DSC/HF distress signal was received and reported to JRCC Victoria. Attempts were made to contact COMSTA Kodiak via 2182.0 KHz telephony, but communication could not be established. Also, no other coast station confirmed that they received our transmission. Analysis 10.1: There is a definite concern regarding the lack of acknowledgement to the DSC alert. The communication loop needs to be closed. The 17 minute time lag between sending the DSC/HF distress message and receiving a response back would in many cases be too late. Potential reasons for failure of COMSTA Kodiak to acknowledge signal include frequency propagation issues, or lack of training by watch-standers. Recommendation 10.1.: It is recommended that further exercises be conducted to determine the possible reasons that the ship did not receive an acknowledgement message and why voice communications were so poor. Recommendation 10.1.2.: Conduct an additional test of GMDSS/DCS in the same position and verify acknowledgement from COMMSTA Kodiak back to the vessel. 48 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 ********** Observation 10.2.: The AIS Search and Rescue Transponder (SART) signal was received up to 10 miles (maximum distance tested) when the unit was elevated above the water on the deck of the ship. When the unit was placed in the water, the signal was picked up at 2.5 miles, but not at 5 miles. This is most likely due to the fact that the SART would lie on its side when in the water. Analysis 10.2: The AIS shows great potential as a replacement for the radar SART as it can not be received by shore sites without the use of radar, nor does it need to be in visual range (i.e. it can be picked up behind islands). The technology would also be valuable for other applications such as a datum marker buoy or as a portable beacon that could be placed on board small craft operating independent of the mother ship. The issue of floating upright does however need to be addressed. Recommendation 10.2.: Further testing of the AIS SART is recommended. 49 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 SECTION 4: CONCLUSION The Alaska Mass Rescue Operation 2009 exercise was successfully conducted. It brought together an extensive emergency response and management system that demonstrated the ability to effectively mitigate a catastrophic Mass Rescue Operation. Importantly, it provided the agencies and personnel necessary to implement process improvement the opportunity to work together, develop an understanding of capabilities, and experience first hand the need for coordinated improvement. Although the response organization demonstrated the ability to respond to the scenario presented, there were areas for improvement. The exercise identified four areas that are recommended for additional planning efforts by joint industry and government work groups to improve process management and develop new or improve existing job aids or other response tools. The four areas are: • The ramp up of and coordination of an ICS organization that occurs when the unified commanders are initially remotely located from one another. • The evacuee accountability process and its’ integration / coordination with other shore side support functions. • The establishment and operation of landing sites. • The establishment and operation of reception centers. Additionally, and this carries over from past exercises and responses, the continued investigation for use of technology to support our efforts, especially accountability procedures, is required. Alaska is somewhat unique with its vast size and remote ports and associated operational challenges. Response is truly a unified effort that requires industry, local, state and federal partnerships and trust for success. The better our procedures and standardization, the better our response tools and training and the clearer our expectations, the greater our success. The procedures, guidance, and tools developed or improved by responders during this exercise have applicability to other ports and regions and planners should strive to produce the best guidance available. 50 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 APPENDIX A: IMPROVEMENT PLAN The key items identified for improvement in this plan are ones that require a “unified” effort. To begin the effort, the establishment of joint work groups is recommended. Work groups will be composed of representatives from the cruise lines and local agents, community officials, medical professionals, USCG representatives, and state officials. The exact agency or individual will be determined by the issue. Currently, three work groups are recommended. One each for: • Unified command coordination improvement • Accountability process improvement • Landing site, triage area, and reception center improvement. Responsibility: It is recommended that USCGD17(dr/dp) be responsible to direct the establishment and work efforts for each of the work groups listed above. The main point of contact will be: Rick Janelle USCGD17(dp) 907-463-2808 firstname.lastname@example.org Personnel interested in being part of the work groups are encouraged to volunteer. Time Line: Initial planning and drafting of preliminary improvement documents will start upon approval of this report. Anticipated start of joint activity is October 2009 after the completion of the summer cruise and tourist season. 51 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 APPENDIX B: EXERCISE DESIGN LESSONS LEARNED Summary: 1. The exercise accomplished main objectives and provided opportunity for majority of response partner in a MRO incident to gain experience and identify areas of improvement. However, there were some key areas of exercise design and control that can be improved in future exercises. Issue 1: Use of Cards to Represent Evacuees: The recruitment of a sufficiently high number of volunteers to role play evacuees is difficult, especially in small communities. This lack of real people may require the use of name cards or tags to simulate a higher number of evacuees. In this exercise about 160 real life volunteers were used to simulate 720 evacuees. 100% accountability of the 720 evacuees on the second day of the exercise was not achieved due to a design failure of the name “cards” used to simulate passengers/crew. For a reason that remains unclear, approximately 60 cards that were injected into the system were lost. They may have been lost because the individual volunteer that was assigned the cards forgot or failed to turn them in, or the cards were left on the bus, or any number of reason. Consequence: Due to loss of cards that represented evacuees, achievement of 100% accountability was not possible. Analysis: The use of name tags/cards to represent individuals for tracking purposes presents problems. If possible, the best solution is to use real people. One volunteer represents one evacuee. It did not appear that a briefing of the players occurred at each transition, boat to dock, dock to bus, and bus to reception center. So they understand how the people were being counted. Nor did it appear that we had a controller at each location to facilitate that process for example “these 10 people on the bus represent 50 people”. That was the intent, but it got lost during the confusion of loading the volunteers on the buses initially. Recommendations: 1. To the maximum extent possible, use real people even if they need to be processed more than once through the system. 2. If cards are used, have each person represent a consistent number of evacuees. Example: One volunteer represents five evacuees. Consistency will benefit exercise players. They know what to expect. 3. Develop a means to track and collate the names of the volunteers with the names of the evacuees they represent. If names come up short, this tracking system will help isolate the source of the problem. 4. If name cards are used, they should be placed on a lanyard around the neck of the volunteers to prevent loss. The total number of evacuees represented by the singe volunteer should be clearly visible to exercise players. 52 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 ********** Issue 2: Control: In this event, the Exercise Director failed to effectively use the talents and expertise of all members of the exercise design team to maximum benefit. The Director became involved in too much detail that resulted in failure to inject many of the MSELs that were scripted. Analysis: The main failure of the Exercise Director was failure to utilize the expertise and experience of the USCG Exercise Support Team (EST). The EST skill set would have resulted in better control of the time line and injects. Recommendations: 1. All exercise control assignments and expectations must be clearly identified and understood. 2. If involved, the skills of the EST must be fully utilized. 3. The Exercise Director should not be involved in the details of managing exercise control, but should focus on resolving conflicts that may arise. ********** Issue 3: Include Ship Personnel in Execution of Exercise. During the 2007 MRO exercise in the Caribbean, ship’s crew were directly involved as exercise players. In the Alaska exercise, no ship was in port, so real ship crew members were not used in exercise play. Analysis: In an actual event, ship personnel would be directly involved in the care and accountability of evacuees, and would support tallying numbers of rescue boats. During this exercise, conflicts arose when the rescue vessels operated by Allen Marine were unable to provide accurate numbers of evacuees on board. This was the result of the short amount of time to report; the confusion represented how the “cards” factored into the total count, and the lack of any shipboard role players to support this activity. Recommendations: 1. If actual ship personnel will not participate in the exercise, exercise design must assign role players to complete those actions that would normally be completed by crew members. These actions include recording the names or numbers of evacuees on each rescue vessel, escorts for evacuees, and other duties. For practical purposes, the use of agents or company personnel is preferred 2. If we are going to use the ship board personnel to make the reports we need to brief them, or one of the controllers should be with the vessel operator and give him the information they need to report. 53 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 ********** Issue 4: Role identification for controllers and evaluators. There were a number of assignments for controllers and evaluators for the second day of the exercise, it did not appear clear what all these people were supposed to do. Analysis: There were a large number of “orange” hats on the dock, the buses and the Allen Marine boats. It was unclear what these people were doing most did not have and notes or evaluation check off sheets. Many times they seemed to be in the way with lots of discussion between them. Part of the issue may have been the hats; all of us having the same color hat indicated the same role which was not the case. There were sufficient “hats” in the area to have given specific assignments to help reduce some of the confusion over the “numbers” of survivors. Recommendation: If we are going to identify roles and locations for controllers and evaluators we need to develop a description of what they should be doing and how or when they should interact with the players. Part of this could have been alleviated if different roles had different hats. Adopt the Homeland Security Exercise and Evaluation Process (HSEEP) and utilize the pre-identified color designations for assigned roles and positions. Definitely the SAFETY folks should have been easier to identify AS IT WERE they just blended in with all the other orange hats. ********** Issue 5: Volunteer movement/control. Prior to the days of the exercise there was a very good effort to solicit volunteers and the people were very cooperative. Their cooperation was instrumental to the success of the exercise but we could have done a much better job. Analysis: Each time we had a public gathering of the volunteers we were running to catch up. We were not ready to process them or to properly greet them. For the first briefing we did not have the tables set up in a fashion that would facilitate easy movement of the registration. The second meeting was better but we were still running to get set up. Many people jumped in to help but we needed designated people who were briefed on the process and what needed to be done. The movement of the volunteers from the center to the dock was a complete cluster, with no direct coordination between the buses, locations and times. Much of this was the poor location where the buses were not able to maneuver. The other time sink was the moving of the handicapped volunteers and the right buses. What did work well was the intervention of some of our volunteers who were also employees of the bus company. The movement of volunteers on the morning of the exercise took too many peoples attention and consequently we were not in place in other important locations to better coordinate the exercise i.e. the dock and boats. Recommendations: 1. There needs to be assigned a volunteer coordinator for responsibility for setting up meetings, coordination with transportation, and keeping all concern on the number and 54 of 55 Final AFTER ACTION REPORT/IMPROVEMENT PLAN Alaska MRO Exercise 2009 types of volunteer. Preferably a local person with a number of assistants. In out case it could have been those who were assigned to ride the buses that would have freed up those who had other assignments. 2. Set up of each function should be done at least 30 minutes prior to the opening of room and people designated to assist. Set up should include a greeter, and a sufficient number of people at each table with the required paper work. It would also help if we had lap tops so we could keep an up to date list of volunteers. The lay out of the greeting area should be sufficient to move people along easily. 3. The gathering place and the transportation of the volunteers on the day of the exercise needs to be reviewed by the volunteer coordinator and the transportation company ahead of time to ensure we have easy in and out access and sufficient space to wait. In the case of Ketchikan a much better place for the volunteers to meet would have been the reception center. 55 of 55 Final