PROTOCOL SNAFU BLOCKS WARNINGS
It wasn't a drill, when equipment from Clackamas Fire District #1, Portland Fire and Rescue and area police bureaus raced to the Clackamas County line outside of Precision Castparts Corporation on S.E. Johnson Creek Boulevard in the late afternoon of Wednesday, May 11.
Like many who live in the Brentwood-Darlington and Ardenwald neighborhoods not far from Precision Castparts, your reporter watched an orange-colored cloud arise from the plant a little after 5:30 pm, and experienced a slight burning sensation in our eyes.
Grabbing camera gear, we headed south on S.E. 52nd Avenue in the Errol Heights area, and watched as Woodstock's PF and R Engine 25 rolled into the former White Stag factory parking lot off S.E. Harney Street. A Milwaukie police officer lit flares at the intersection.
'We're being told to move back, up the hill,' the officer told us. 'A hazardous gas has been released down below.'
Steve McAdoo, Clackamas Fire District #1's Public Information and Community Liaison Officer, called a press conference via Twitter, and explained that at 5:37 pm, that there had been a possible hazardous materials incident at 5100 S.E. Johnson Creek Boulevard. 'The call from the Precision Castparts told the 9-1-1 operator that a chemical reaction in progress was creating an orange cloud coming from the building.'
What caused the toxic vapor release, McAdoo said, was power surge that had occurred as workers dipped a 700 lb piece of titanium into a chemical bath containing hydrofluoric and nitric acids. This process cleans silica off the titanium - a process that causes an off-gassing of these chemicals.
The power surge not only locked the crane in the 'down' position - it also killed the 'air scrubber' that cleans the air before it's released into the neighborhood, McAdoo explained. 'When the back-up generator started, a breaker panel failed, and the equipment could not be re-engaged. The titanium then remained in the chemical, instead of being taken out, as is part of the normal process.'
Firefighters determined it was too dangerous to enter the building and to try to stop the reaction. 'Gas continued to sporadically flow from the building, heading in a northerly direction over the neighborhood directly north of the building,' McAdoo said. 'The first priority was the safety of personnel, the employees, arriving firefighters, and the public.'
Residents in the Brentwood-Darlington neighborhood to the north and east were advised to 'shelter in place', via social media, and radio and television stations, McAdoo said.
However, residents not tuned in to broadcast media, or looking at the Internet, continued to wonder if they were in danger. Many only later got the 'shelter in place' advisory from front-line public safety personnel blocking streets leading to the plant throughout the night and into morning hours.
By nightfall, S.E. Johnson Creek Boulevard became a virtual parking lot, populated with additional equipment and crews - including those from the Oregon State Regional Hazardous Material Team from Gresham Fire.
'After conferring with PCC, the State Hazardous Material team members, the Incident Command determined that the safest response was going to be to let the chemical reaction run its course,' McAdoo said. 'The off-gassing would become less crucial as every minute passed, as the silica was cleaned from the titanium.'
Automated warning calls
Emergency managers offered to activate the Clackamas County Emergency Notification System - an automated system that calls published telephone numbers of area residents to warn them of such an incident. 'The offer was declined because the current winds and predicted winds were flowing away from the plant away from Clackamas County,' reported McAdoo.
But to the north, where the toxic vapor cloud was drifting, the telephones remained silent. Only those tuned in to broadcast media - or who followed certain social media - knew of the potentially dangerous situation that sent two employees and two first responders to the hospital for treatment of what McAdoo characterized as 'respiratory irritation'.
As predicted by experts at the scene, the readings of hazardous airborne chemicals gradually declined, until an 'all clear' was given about 18 hours after the incident began.
When many Brentwood-Darlington residents later asked why Portland's 'Reverse 9-1-1' telephone call-out system wasn't activated, the question was directed to the Portland Bureau of Emergency Communications (BOEC).
'BOEC doesn't operate that system,' responded the spokesperson, Jacquie Carson. 'It's operated by the Portland Office of Emergency Management (POEM).'
On May 17, Dan Douthit, POEM's acting public information officer explained that BOEC and POEM were holding a meeting with PF and R about this matter. 'They'll be looking into as to exactly what happened, and reviewing the incident to learn why the joint City/County Community Notification System wasn't activated.'
As promised, Douthit later sent a 1,300-word document arising from that meeting, which was held on May 18, entitled, 'Analysis of the chemical release at Precision Castparts, and Portland's use of the community notification system'.
The document verifies that Portland's 'Reverse-911' system was not activated at any point during the incident.
It also observes that because Precision Castparts straddles two counties, 'multiple emergency communications and management agencies were involved,' adding that, 'During the incident, there was a lack of adequate and clear communication between the multiple agencies as it related to the community notification system.'
The document says this notification system, called 'FirstCall', is a 'joint effort with Multnomah County, managed by POEM and Portland Water Bureau.'
Although the system was installed back in December, 2010, the POEM's protocol document to guide its use, called an 'Alert and Warning Annex', has yet to be adopted by the Portland City Council (it's scheduled for a vote in June).
What actually happened to warning calls
The published document reports that at 6:04 pm, Clackamas Fire asked Clackamas County Communications (C-COM) to contact the Portland Bureau of Emergency Communications (BOEC) to activate Portland's community notification system - to notify residents in the affected area, as an additional means of informing the public.
The BOEC supervisor on duty was not aware of Portland's new 'FirstCall' Reverse-911 calling system, which was installed in December, 2010.
After receiving notification of the incident from Multnomah County's Emergency Manager, David Houghton, and Portland Office of Emergency Management (POEM) Bureau Director Carmen Merlo, called the BOEC supervisor around 6:40 pm to learn more about the situation.
At that time, Merlo learned that BOEC had tried to activate the Portland Emergency Notification System (PENS) system. This was the prior emergency calling system, and it had been removed when 'FirstCall' was installed last year.
The BOEC supervisor asked Merlo how the FirstCall system could be activated, and whether Merlo was the contact. Merlo confirmed that she is the contact. During the conversation, the BOEC supervisor did not ask Merlo to activate the FirstCall system, nor did Merlo ask the BOEC supervisor whether the FirstCall system needed to be activated.
At 9:53 pm, Clackamas Fire again asked for activation of Portland's community notification system. At 9:59 pm, BOEC responded that the community notification requested earlier had not occurred, but that POEM could respond to the new request using the 'FirstCall' system. C¬COM contacted the POEM duty officer at 10:25 pm about using 'FirstCall'.
At 10:27 pm, Merlo received a call from William Warren, POEM's duty officer that evening, to indicate Clackamas County had requested the use of the FirstCall system.
At 10:29 pm, Merlo contacted C-COM to get text of message for community notification and confirm authorization by Clackamas Fire incident command. C-COM provided the number of the incident commander for her to contact directly.
At 10:37 pm, Merlo left a voice message with the Clackamas Fire incident commander to confirm the message and authorization.
At 10:42 pm, Merlo received a call from the Clackamas Fire incident commander, and discussed whether to issue an alert this late in the evening, given that there was no new information (although the information had not yet been sent to residents using the emergency system). The incident commander indicated he would call back after further discussion.
At 11:06 pm, Merlo contacted the incident commander to find out whether to launch or hold off.
At 11:10 pm, Merlo received call back from incident commander indicating he would hold off on using the 'FirstCall' system that evening, but could ask for notification to be done in the morning. The incident commander did not request a notification the next day.
The outcome of the investigation
The report concluded that while an 'Alert and Warning Annex' had been developed, additional training on steps to activate the system would still be needed. Training on the use of the system is to be conducted for BOEC and Portland public safety and emergency response bureaus.
The 'Alert and Warning Annex' has now been updated to clarify the current procedure for activating the 'FirstCall' telephone system.
The 'Annex' now clearly states: 'Requests for activation of the 'FirstCall' community notification system must be coordinated through POEM via the Duty Officer or POEM Director. If another bureau or agency has requested the activation of the community notification system, the Duty Officer will immediately notify the POEM Director.'
Clear protocols seem now to be in place at BOEC for dispatch supervisors to page the POEM duty officer for requests to activate the 'FirstCall' system. BOEC will also develop internal protocols for the direct use and activation of the 'FirstCall' system.
City Commissioner Amanda Fritz speaks
At an unrelated public event on May 26, we asked Portland City Commissioner Amanda Fritz, who oversees BOEC, to comment on the seemingly Byzantine protocol for activating this potentially life-saving system.
In conversation, Commissioner Fritz said that, while she's received a number of communications regarding this event, she can't speak for POEM. This agency, we later learned is in Commissioner Randy Leonard's portfolio, and is now under the direction of Portland Mayor Sam Adams.
Fritz did say, as the Commissioner in Charge of BOEC, that she was very aware of the situation. 'I am concerned about coordination with POEM; and about the buying and installing [of the 'FirstCall'] system while the protocol for its operation would not be coming before the Portland City Council for another six months.'
While Precision Castparts has a stellar record of safe operation, and for containing toxic spills within their facility - the firm has large quantities of toxic material on hand that workers use every day - the potential for disaster of remains.
Oddly, few in City and County emergency management have expressed concern that not all emergency notification systems may currently be fully operational.
If the City ever does get 'FirstCall' into use, you should know that not all telephone numbers - especially celular phone numbers - are in the FirstCall system. To make sure your number is listed in the FirstCall database, sign up on the City's website online at: www.publicalerts.org .
Meantime, Brentwood-Darlington neighbors - those who live uphill, and typically upwind, of Precision Castparts - tell THE BEE that they hope that someday they can feel confident that ALL communications methods - not just broadcast and social media - can and will immediately be used, should such a similar situation ever arise again.