Overview: As you learned in the CPG 201 document, Step 1 of the THIRA process involves the identification, definition, and prioritization of risks and hazards. We will be using the Graniteville, SC t
EMH201 – Risk and Vulnerability
Assessment
Course Project: THIRA Step 1 Worksheet
Review the scenario below and reference the Community Lifelines Presentation in readings and resources to fill in the worksheet.
Many trains traveled through the quiet mill town each day. A rail spur in the center of the town serviced the Avondale plant, which employed most of the town’s citizens and received daily deliveries of chlorine gas via a Norfolk Southern train for mill operations. The switch connecting the spur to the main line had to be turned manually for deliveries. Contributing to the failure, no feature or mechanism existed to remind crewmembers of the switch position and prompt them to complete the switch before departing the work site. The investigative team of the National Transportation Safety Board (NTSB) concluded that “the distance required for the [moving] train[‘s] crew to perceive the banner of the misaligned switch, react to it, and brake the train to a safe stop was greater than the distance available” (2).
The chlorine spill occurred as the result of a train crash at 2:39 a.m. on January 6, 2005, after someone forgot to toggle the switch to disconnect a spur from the main line (Figure 2). The incorrectly toggled switch mistakenly diverted Freight Train 192 from the main line onto the spur at 47 mph (76 km/h). Train 192 subsequently collided into parked Train P22, derailing three engines and 18 cars (3). Roughly 60 tons of liquefied chlorine gas spilled out of the ninth of 42 freight cars. The liquefied gas rapidly vaporized, with volumetric expansion 450:1 (4).
The engineers were unharmed in the crash; however, the deadly chlorine gas seeped through the air. The crash sound awakened local residents, and initial notification came through a 911 call within 1 min. The Aiken 911 call record indicated reports of a “bleach gas smell and smoke on the ground,” and at least one caller identified chlorine (5). Fire and rescue services responded within 1 min of notification and were enroute within one more minute; however, upon hearing a radio report of a “smell of chemicals,” the fire department chief ordered responders to stand by. Within 6 min, the fire department chief stood 1,000 ft (305 m) from the crash and was forced to withdraw lest he be overcome by chlorine fumes, which were spreading rapidly and approaching critically toxic levels. Within 13 min, the chief recognized the need for a mass evacuation and relocated upwind. Emergency responders marshaled personnel and equipment, established incident command, requested mutual aid, activated Reverse 911 with instructions to shelter in place, and initiated a major evacuation (6). However, these actions did not take place with immediacy and efficiency.
About 5,400 residents were evacuated. The chlorine gas had already affected many people: 554 were treated at hospitals, 75 were admitted, and nine would eventually die from its poison (2): the train’s engineer (who had survived the crash), three workers in the mill, a truck driver sleeping in his cab, a man in a shack one block from the wreckage, two workers who had evacuated the mill on foot into the woods, and one other person (7).
*Note: There may be more than one correct Community Lifeline impacted.
| Risk item | Context Description | Priority – Based on Likelihood & Impact | Core Capability & Mission Area | Community Lifeline Impacted |
| Residential Alerts & Warnings | A variety of sound-powered, voice, telephonic, light, digital, and broadcast alarms that are easily recognized by all members of the community | Public Information & Warning (Response mission area) | ||
| Emergency Operations Center | First responders lacked dedicated space, equipment, and personnel to staff a full-time emergency operations center | 11 | Operational coordination (Response mission area) | |
| Emergency Dispatching | Law enforcement dispatching was delayed due to problems with reverse 911 system | 13 | Operational coordination (Response mission area) | Safety & Security Communications |
| Inadequate hazardous chemical detection | Law enforcement and fire personnel lacked adequate chemical detection equipment to classify and monitor toxic levels on scene | Environmental Response/Health & safety (Response mission area) | Safety & Security Hazardous Material | |
| Inadequate hazardous chemical decontamination | On scene personnel lacked adequate equipment to decontaminate victims and first responders entering/exiting hot zone | Environmental Response/Health & safety (Response mission area) | Safety & Security Hazardous Materials | |
| Inadequate hazardous chemical identification | Law enforcement and fire personnel lacked adequate chemical detection equipment to classify and monitor toxic levels on scene | On-scene protection, law enforcement, and security (Response mission area) | ||
| Inadequate hazardous chemical protective equipment | Law enforcement, EMT, and medical personnel lacked adequate personal protective equipment to rescue, recover, enter, and exit hot zone. | 14 | On-scene protection, law enforcement, and security (Response mission area) | Safety & Security Hazardous Materials |
| Freight carrier disruptions; debris blocking routes | Rail cars littered north and south-bound tracks of major freight route for weeks after incident was resolved. Debris was contaminated and in need of cleaning prior to removal. | 20 | Economic recovery (Recovery mission. Area) | Transportation |
| Mass victim transport | Local ambulance carriers were overwhelmed by requests for victim transport | Mass care services (Response mission area) | ||
| Victim treatment at local hospitals | Contaminated victims presenting at local hospitals overwhelmed treatment room capabilities and cross-contaminated emergency rooms | Mass care services (Response mission area) | Health & Medical Transportation | |
| Exposure to chlorine long-term health effects | Residents of Graniteville were not monitored by public health professionals after incident was resolved | 18 | Health & Social Services (Recovery mission area) | Health & Medical |
| Resident evacuation | Residents unsure of shelter in place or evacuation procedures | Environmental Response/Health & safety (Response mission area) | ||
| Law Enforcement lacked protective equipment | Responding Sheriff Deputies lacked protective clothing and breathing equipment to occupy and enforce protective zone around incident scene | Environmental Response/Health & safety (Response mission area) | Safety & Security | |
| Local search & rescue | Residents in the immediate area of contamination were unsure of shelter in place, evacuation routes, and safe distance rally points after incident occurred | Mass search & rescue operations (Response mission area) | ||
| Inadequate mutual aid agreements | Graniteville lacked expertise in development, exercise, and socialization of mutual aid agreements with surrounding communities | 12 | Planning (Response/Mission Area mission area) | |
| Inadequate rail switch equipment | Workers at Avondale Mill incorrectly set the rail switch to the wrong position, resulted in train being re-directed to the wrong route | 19 | Critical transportation (Response mission area) | |
| On-scene command & control | Incident command for on-scene control of the incident was delayed due to lack of personnel and equipment. | 10 | On-scene security & protection (Response mission area) | |
| Evacuee food support | Victims lacked access to food and food preparation facilities after incident was resolved | 15 | Infrastructure (Recovery mission area) | Food, Water, and Shelter |
| Evacuee water support | Victims lacked access to adequate water after incident was resolved | 16 | Infrastructure (Recovery mission area) | |
| Evacuee housing support | Victims lacked adequate housing after incident was resolved. | 17 | Housing (Recovery mission area) | Health & Medical Food, Water, and Shelter |
Resources
Department of Homeland Security. (2018, May). Threat and hazard identification and
risk assessment (THIRA) and stakeholder preparedness review (SPR) guide, comprehensive preparedness guide (CPG) 201, 3rd edition. Washington, DC.
Dunning, A. E., & Oswalt, J. L. (n.d.). Train wreck and chlorine spill in Graniteville,
South Carolina. United States Department of Transportation.
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