EPA'S RESPONSE TO THE WORLD TRADE CENTER COLLAPSE: CHALLENGES, SUCCESSES, AND AREAS FOR IMPROVEMENT |
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40 Report No. 2003-P-00012 A critical component in helping the public minimize exposure to potential health hazards resulting from a terrorist attack or other disasters involves communicating risk information to the public. Armed with such information, the public can take positive steps to mitigate potential exposures as well as other precautions to avoid unnecessary health risks. After the terrorist attack on WTC, government communications were criticized for not providing timely and accurate information to the public. Evidence gathered through studies and various governmental hearings indicates that the public and Ground Zero workers did not receive sufficient air quality information, wanted more information on the associated health risks, and did not consistently take precautions recommended by government communications to minimize their health risk. Because of these concerns, the OIG conducted a survey of New York City residents regarding government communications. These results will be reported separately. From October 25 through November 1, 2001, NYCDOH conducted a door-to-door survey of residents in Lower Manhattan’s Battery Park City, Southbridge Towers, and Independence Plaza. All of these neighborhoods were in close proximity to the WTC towers. A representative sample of apartments from each of these three areas was selected and a total of 414 interviews were conducted. The survey reached two conclusions related to air quality:
Specifically, in regard to air quality information, the report noted that: The topics of most interest to this population related to air quality, its safety and its effect on the physical health of both adults and children (70% said they wanted more information about air quality). There is a 41 Report No. 2003-P-00012 need for more information regarding the potential risks from exposure to the dust and debris that continues to be emitted from the WTC site. Related to this topic, 35% of the respondents reported that they needed more information regarding cleaning. The report noted that only 40 percent of the residents said they cleaned their homes according to the recommended methods of wet moping hard surfaces and using HEPA vacuums on carpeting. The report noted two limitations on its results. First, the survey only included three selected neighborhoods in Lower Manhattan and did not include residents who had not re-occupied their apartments at the time of the survey. Second, the report noted that normally respiratory symptoms (e.g., symptoms related to allergies) increase during the time of year the survey was conducted. Hearings held by a Congressional Subcommittee, the EPA Superfund Ombudsman, New York City Council, and New York State Assembly included testimony indicating that the public desired more information regarding air quality. Further, several reports detailing lessons learned from the WTC response noted problems with government communications regarding air quality. These reports and their conclusions are discussed in Chapter 7. Telephone Poll Indicated Public Did Not Believe Air Was Safe A telephone poll [13] conducted in March 2002, after many news articles were published questioning the air quality information that the government had issued, found that 70 percent of those surveyed did not believe environmental protection and other government agencies when they said the air quality around the WTC site was safe. The poll surveyed 511 randomly dialed residences from the five boroughs of New York City. We contacted one of the principals of the polling organization, who told us the answers to the lone question asked about air quality were consistent among all groups polled. Unprotected Workers Cleaned Contaminated Offices and Residences Preliminary results of an independent study [14] of the health of day laborers who cleaned indoor spaces near Ground Zero noted that these workers were generally not provided with respirators or any personal protective equipment. Further, the workers were not informed about the contents of the dust they removed from offices and apartments, nor were they informed of any environmental test results _______________ 13 Blum and Weprin Associates, New York Daily News, March 2002, margin of error plus or minus 4.5 percent. 14 “Assessing the Health of Immigrant Workers Near Ground Zero: Preliminary Results of the World Trade Center Day Laborer Medical Monitoring Project”; Ekaterina Malievskaya, M.D., Nora Rosenberg, Steven Markowitz, M.D.; American Journal of Industrial Medicine; December 2002. 42 Report No. 2003-P-00012 on the dust and debris that they removed. Moreover, most of these workers reported health symptoms that first appeared or worsened after September 11, 2001. These symptoms included coughing, sore throat, nasal congestion, chest tightness, headaches, fatigue, dizziness, and sleep disturbances. The results were based on examinations of 418 workers from January 15 through February 28, 2002. Ground Zero Workers May Not Have Received Sufficient Information A widely publicized aspect of the WTC response was the lack of respirator use by rescue and construction crews. It was beyond the scope of this review to determine the extent that respirators were not used and why this occurred. However, we reviewed EPA’s efforts to provide respirators, reviewed accounts of respirator use in various articles and reports, and inquired about respirator use and availability during our interviews with EPA, other Federal agency, New York City, and non-government officials. Our limited work in this area indicated that respirators were generally available but were not worn for a number of reasons. A significant factor was the desire to save lives without regard for personal safety in the immediate aftermath of the disaster. Other reasons appeared to include the respirators’ interference with the ability of emergency workers to communicate, lack of training, lack of enforcement of safety measures at the site, and conflicting messages about the air quality at Ground Zero. A detailed discussion on the use of respirators by rescue and construction crews at Ground Zero, including EPA activities to encourage respirator use as well as the health impacts of the lack of respirator use, are in Appendix L. A January 2002 report [15] concluded that respirator use was compromised, in part, due to mixed messages that workers received about the importance of respiratory protection. For example, the report noted that air monitoring information was often within OSHA permissible limits or below the analytical method limit of detection. Thus, on one hand workers had information suggesting that the air quality was not bad, but a message to wear respirators on the other. This report also noted the poor example set by political figures, celebrities, and even supervisors who visited the site but did not wear respirators. The experiences of the Laboratory Director of an environmental testing firm hired to conduct testing for one of the companies conducting the site clean-up was consistent with information presented in the report on respiratory usage at the WTC site. This individual, with many years experience in asbestos toxicology and applied environmental hygiene, told us that he interpreted EPA’s statement that the air was safe to breathe to apply to Ground Zero. The Laboratory Director _______________ 15 “Respiratory Protection at the World Trade Center: Lessons From the Other Disaster,” Bruce Lippy, CIH, CSP, January 15, 2002. 43 Report No. 2003-P-00012 said that the construction company that hired him also interpreted EPA’s statement to apply to Ground Zero, and on the basis of EPA’s statements about air quality, company officials questioned the Laboratory Director’s recommendations that workers wear respirators. Although he was able to convince his client that respirators were needed, he told us that it was difficult to convince workers to wear respirators. A November 2001 report [16] prepared for the National Council of Structural Engineers Associations - Structural Engineering Emergency Response Plan Committee similarly noted that structural engineers at the site had concerns about environmental contamination at Ground Zero but proceeded with their work given the urgency of the situation. The report noted that although structural engineers assumed the air quality was being monitored by government agencies, specific information on the results of this monitoring did not filter down to the structural engineering teams. Further, structural engineers did not know if they were wearing the correct respirators. The report cited the following joint EPA and OSHA statement as an example of information that the authors concluded did not provide sufficient information on air quality or the proper respirators needed: . . . EPA and OSHA are providing real-time analysis in the immediate vicinity of the debris pile at Ground Zero. . . . . . This information helps response workers on the scene determine what level of respiratory protection is appropriate to use (U.S. Dept. of Labor Press Release 01-339) EPA has initiated several actions to improve its risk communications to the public. These actions are discussed in Chapters 2 and 7. In regard to worker safety, EPA is participating in a FEMA-led Interagency Health and Safety Coordinating Committee to provide unified safety and occupational health leadership, guidance, and policy development for all Federal agencies under the Federal Response Plan. In particular, the Committee plans to develop an Emergency Support Function for Safety and Occupational Health. The public wanted better information about air quality than they received from government sources. A NYCDOH study, other lessons learned reports, and testimony provided at various hearings suggest that the public did not receive adequate air quality information and that individuals cleaned their residences without using proper procedures and personal protection. In addition, workers at _______________ 16 “World Trade Center Disaster: Structural Engineers at Ground Zero,” August Domel, Jr., Ph.D., S.E., P.E., November 2001. 44 Report No. 2003-P-00012 Ground Zero may not have used respirators due, in part, to inadequate EPA and other government communication. EPA was one of many governmental and non-governmental agencies that communicated health risk information to workers and the public. The levels of non-adherence to the risk communications of these governmental agencies suggests that all the participating levels of government need to re-examine their policies, procedures, and practices for ensuring that necessary precautions are consistently followed to reduce human exposure to contaminants. We recommend that the EPA Administrator: 5-1. Coordinate with FEMA and other applicable Federal agencies to clearly establish Federal agency responsibilities, roles, and procedures during an emergency response that ensure that:
Additional recommendations relevant to the issues discussed in this chapter are included in Chapters 2, 3, and 7. Also, additional recommendations may be presented in our subsequent report on the results of our public survey. Agency and New York City Comments and OIG Evaluation EPA agreed with the recommendation but noted that it and other Agencies provided the public with the most comprehensive and up-to-date information available. In regard to worker safety, EPA noted that it supported OSHA in many ways, including a long-term effort to educate workers about the need to wear respirators. The Agency’s complete written response to our draft report and our detailed evaluation of that response are contained Appendices Q and R, respectively. 45 Report No. 2003-P-00012 New York City officials responded that our report should not discuss respiratory issues related to Ground Zero since this was OSHA’s responsibility and not EPA’s. New York City offered several revisions to this section if we were to retain it in our report. We incorporated New York City’s suggested changes where appropriate but have retained our discussion of respiratory issues as Appendix L since EPA supported OSHA in this activity. New York City’s response to draft report excerpts and our evaluation of that response are contained in Appendices S and T, respectively. 46 Report No. 2003-P-00012 Further Actions Needed to Address Current WTC Response Monitoring data showed that ambient air levels in Lower Manhattan had generally returned to pre- September 11 levels in mid-2002 or earlier, and as such, EPA ceased outdoor monitoring in June 2002. Further, all debris had been removed from the site by June 2002. However, concerns about indoor contamination resulting from the collapse remained at the time we completed our review in April 2003, even though EPA, FEMA, and New York City had initiated a multi-million dollar Indoor Air Residential Assistance program that included testing and cleaning of residences in Lower Manhattan. Additional measures can be taken to ensure cleanup provides reasonable assurance that the public’s exposure to asbestos and other contaminants in residences and workspaces in Lower Manhattan is within the acceptable risk guidelines. WTC Outdoor Monitoring Ended June 2002 EPA ceased all WTC-related outdoor air monitoring in Lower Manhattan on June 20, 2002, with EPA concluding that, for the most part, outdoor ambient air pollution levels had returned to pre- September 11 levels. Generally, ambient pollutant levels in Lower Manhattan noticeably decreased in January 2002, once the fires at Ground Zero were essentially extinguished. Some spikes in benzene were recorded in January and February 2002, as a result of fires that flared up during removal operations. From March 2002 through June 20, 2002, the only elevated readings recorded were for asbestos. The elevated readings occurred in March and April 2002 at the worker wash station and in May 2002 at the monitoring site near the barge operation. Our review of monitoring data as well as discussions with EPA, other Federal agencies, New York City, and selected external health research, air quality testing, academic, and environmental organization officials supported EPA’s view that the outdoor ambient air pollution levels in Lower Manhattan had, for the most part, returned to pre-September 11 levels for those pollutants where pre-September 11 monitoring data existed. Indoor Residential Cleanup Program The testing and cleaning of residences was one of several activities included in an overall Indoor Air Residential Assistance Program funded by FEMA at an estimated cost of $60 to $80 million. In addition to testing and cleaning of residences, the program included: 47 Report No. 2003-P-00012
The indoor residential cleanup program was administered by EPA and New York City. FEMA officials told us that they normally do not fund indoor cleanups of private spaces related to a disaster unless an immediate hazard is declared. FEMA officials told us that New York City officials indicated a formal cleanup program was not needed. Therefore, in May 2002, the EPA Region 2 Administrator provided FEMA with a memorandum that furnished the necessary justification to authorize funding. Public registration for the testing and cleaning program ended on December 28, 2002. As of July 17, 2003, EPA had reported the following test results. Table 6-1: Test Results for Indoor Asbestos Testing as of July 17, 2003
Residents could choose to have “testing only” of their residence or they could choose to have “cleaning and post-cleaning testing” of their residence. Residents requesting to only have their residence tested could choose between one of two sampling options: aggressive sampling or modified aggressive sampling. Aggressive sampling used a leafblower to stir up any settled dust by blowing air against walls, ceilings, floors, and other surfaces prior to collection of air samples. Modified aggressive sampling did not use leaf blowers. For either sampling option, the air samples were to be analyzed for asbestos only. In addition to testing indoor air for asbestos, EPA planned to collect pre- and post-cleaning wipe samples for a limited number of residences (approximately 250) and test these samples for dioxin, total metals, and mercury. For residents requesting “cleaning and post-cleaning testing,” two approaches were used to clean the residences. The cleaning approach was based on the extent 48 Report No. 2003-P-00012 of dust contamination as determined through visual inspection. If a visual inspection of the residence and the building’s common spaces (including elevator shafts) revealed minimal dust accumulations (light coating), “Scope of Work A” applied. If visual inspection indicated large or significant accumulations of dust or debris from the WTC collapse in residences, portions of the residence, or the building’s common spaces, “Scope of Work B” applied. In general, “Scope of Work B” included additional cleaning of surfaces not included in “Scope of Work A.” Appendix M describes the two approaches available for residents requesting cleaning and post-cleaning testing. A significant issue with respect to developing health-related benchmarks (or clearance standards) is the extent of prior or background contamination, particularly in urban areas. This information is needed to determine the impact of a disaster on the indoor environment. Studies have shown that these background levels can exceed concentrations that may present a greater than 1-in-1,000,000 excess lifetime cancer risk (the desired cleanup goal for the Superfund program). In the WTC case, EPA’s background study of Upper Manhattan suggests that the background concentrations for asbestos in indoor air and dioxin in settled dust were at levels that presented a greater than 1-in- ,000,000 excess cancer risk. Concurrent with the start of the indoor cleanup, a multi-agency workgroup of Federal, State and city officials identified contaminants of potential concern (COPC) related to the WTC collapse and developed health-related benchmarks for these COPCs, including asbestos, lead, dioxin, PAHs, fibrous glass, and crystalline silica. Three of these COPCs are considered cancer causing: asbestos, dioxin, and PAHs. For each of the three carcinogens, the workgroup established a health-related benchmark that equated to an increased lifetime cancer risk of 1-in- 10,000. This means that if 10,000 people are exposed to a single COPC at the established benchmark level for 30 years, there may be one more case of cancer than if the group had not been exposed. In September 2002, the multi-agency workgroup published these COPCs in a peer review draft entitled “World Trade Center Indoor Air Assessment: Selecting Contaminants of Potential Concern and Setting Health-Based Benchmarks,” which was peer reviewed by the Toxicology Excellence for Risk Assessment (TERA) organization in October 2002. TERA’s peer review report was issued on February 7, 2003. The group’s suggestions included:
49 Report No. 2003-P-00012 The workgroup issued a revised COPC document in May 2003 that included responses to the peer review panel’s comments. Given the significance of the panel’s comments, the fact that additional information has been developed since the peer review was conducted, and the potential for this document to be used as a basis for future indoor cleanups, we believe the revised COPC document should be submitted for a second peer review as suggested by the TERA panel. The residential cleanup effort represents a significant undertaking by EPA, FEMA, and New York City. Nonetheless, it has been criticized by some groups. The geographical coverage of the cleanup, limited to residences south of Canal Street, has been questioned. The testing and cleanup procedures have been criticized, particularly the fact that EPA has not required all apartments within a building to be cleaned. In addition, not requiring the cleaning of all HVAC systems was criticized as a limitation that could lead to re-contamination of clean residences. Additional actions can be taken to provide greater assurances that the program is fully protective of human health. These actions include:
Discussions on each of these actions follow. Indoor Cleanup Level Does Not Meet Minimum Superfund Levels Although the indoor cleanup in Lower Manhattan was not being conducted as a Superfund cleanup, Superfund regulations and guidelines provide useful criteria for evaluating the health protectiveness of the Lower Manhattan cleanup and whether it provides reasonable assurance that the public’s risk of exposure to asbestos and other contaminants had been minimized. The NCP describes specific criteria for determining the cleanup goals for contaminated sites placed on the National Priorities List. The NCP requires that for known or suspected carcinogens, acceptable exposure levels are generally concentration levels that represent between a 1-in-10,000 and 1-in-1,000,000 increased lifetime cancer risk. The NCP lists nine factors, including cost, 50 Report No. 2003-P-00012 exposure, uncertainty, and technical limitations, that may justify a cleanup remedy that departs from the 1-in-1,000,000 cleanup goal. In contrast to the above criteria, EPA’s Lower Manhattan indoor cleanup established a 1-in-10,000 risk as the goal of the cleanup for asbestos. The program does not include monitoring for the presence of the other COPCs, including dioxin and PAHs, which are known carcinogens. The COPC document established benchmarks for these two pollutants that also correspond to a 1-in- 10,000 increased risk. Although the assumption is that the cleaning methods prescribed for asbestos will clean the residence of other pollutants as well, the post-cleaning testing does not provide assurance that these other pollutants were removed. However, under Superfund guidance, the risk from exposure to multiple carcinogens is considered additive. Thus, if all three pollutants were cleaned up to levels that equate to a 1-in-10,000 risk for each pollutant, the combined risk would be considered greater than 1-in-10,000. The TERA peer review addressed the risk level established for the COPCs. The panel suggested that the document more clearly explain how the impact of being exposed to mixtures of the COPCs was considered in developing the benchmarks. Further, panel members disagreed with the rationale for using an upper level excess lifetime cancer risk of 1-in-10,000. The workgroup’s response to the peer review panel stated the risk level was appropriate because of practical sampling limitations for asbestos, noting a sampling time of 800 hours would be required to achieve the air monitoring results needed to support a 1-in-1,000,000 increased lifetime risk level. The workgroup acknowledged that running multiple pumps concurrently could reduce total sample time, but did not judge this practical since more than 6,000 individual residences signed up for the cleaning program. Need to Treat Impacted Buildings as a System Tests of indoor asbestos contamination have shown that the distribution of asbestos within indoor spaces is not consistent. Selective cleaning of apartments does not ensure that uncleaned residences or uncleaned objects in apartments are free of asbestos contamination. In the case of centralized HVAC systems, selective cleaning does not ensure that cleaned apartments will not be re- contaminated by uncleaned apartments through the HVAC system. Consequently, the cleaning of contaminated buildings should proceed by treating the building as a system. This systematic approach to cleaning would require that the exterior of the building be cleaned first before the building is re-occupied. All possible entrances for outside air should be sealed off and the building HVAC shut down during exterior cleaning. Once the exterior is cleaned, interior cleaning can begin. For buildings with centralized air and heating, the interior surfaces of supply ducts and return air plenums, fan housings, and filter housings should be cleaned. Filters should be removed, filter tracks cleaned, and new filters installed. The above 51 Report No. 2003-P-00012 actions are necessary to prevent uncleaned sub-parts of the HVAC system from re-contaminating the system. When cleaning individual rooms, each air supply or return register should be sealed to prevent re-entrainment of toxicants into the HVAC system. According to EPA officials, as of July 2003, 143 buildings had been cleaned, including 28 HVAC systems. The non-aggressive sampling option available to residents does not provide assurances that residents will not be exposed to potentially harmful levels of asbestos. AHERA protocols for building clearance after abatement require aggressive sampling to re-entrain (stir) settled dust before air samples are taken. The modified aggressive option available to residents may not re-suspend asbestos particles clinging to surfaces within the residence. Comprehensive Health Protection Would Also Include Workspaces EPA, FEMA, and New York City implemented a cleaning and testing program for residences but not workspaces. Some have complained about this limitation, noting that a program of comprehensive health protection would address indoor contamination in workspaces. The EPA Region 2 Assistant Administrator for WTC Recovery Operations told us that EPA had discussed this issue with OSHA, and that workers or employers could contact OSHA if they had concerns about possible asbestos contamination in their work places. Further, EPA indicated that OSHA was prepared to address any workplace issues brought to its attention. Cleanup Boundary Not Scientifically Developed The northern boundary of the cleanup area (Canal Street), coincides with the initial exclusion zone developed on September 11. However, this boundary was not based on systematic and representative sampling to determine the likely outer boundary of WTC contamination. Several indoor sampling efforts were conducted after September 11, but none were designed to determine the geographic extent of WTC dust contamination. Consequently, it has not been determined whether buildings north of Canal Street or east of Lower Manhattan, in Brooklyn, were contaminated. EPA officials told us that the Canal Street boundary represented a conservative one based on visual inspection of how far dust and debris from the collapse traveled as well as their interpretation of various data, including images obtained by overhead flights. We also discussed the path of the dust and smoke plume with an Office of Research and Development researcher. He told us that his modeling demonstration as well as satellite images taken by the U.S. Geological Survey 52 Report No. 2003-P-00012 indicated that dust from the collapse did not extend beyond Canal Street. Environmental experts told us that ideally a sampling plan should have been implemented that collected and analyzed samples starting at Ground Zero and radiating outward in concentric circles until the boundary of WTC contamination was determined. Extensive ambient monitoring data collected after September 11 demonstrated that outdoor air quality levels around Lower Manhattan eventually returned to pre- September 11 levels. As such, EPA does not need to take additional actions to address outdoor ambient air quality concerns specifically related to the collapse of the WTC towers. EPA, in cooperation with FEMA and New York City, initiated a large-scale indoor cleanup. In our opinion, this cleanup should meet the minimum criteria for protecting human health that EPA has established for Superfund cleanups. Also, the indoor cleaning and testing program should employ aggressive testing in all residences and treat buildings as a system. Additionally, EPA should evaluate the potential health risks for pollutants of concern in workspaces and for geographic areas north of Canal Street, in Brooklyn, and any other areas where meteorological data show pollutants of concern may have been deposited. We recommend that the EPA Administrator ensure that EPA Region 2: 6-1. Submit the revised “World Trade Center Indoor Air Assessment: Selecting Contaminants of Potential Concern and Setting Health-Based Benchmarks” document to TERA for a second peer review. 6-2. Implement a post-cleaning testing program to ensure that, in addition to asbestos, the indoor cleanup program has reduced residents’ risk of exposure from all of the identified COPCs to acceptable limits. 6-3. Due to concerns over possible re-contamination of residences cleaned under the Indoor Air Residential Assistance program, EPA should treat buildings as a system and implement a post- leaning verification program to ensure that residences cleaned by the program have not been re- contaminated. 6-4. Work with FEMA and OSHA to assess whether the ongoing residential testing and cleaning program should be expanded to address potential contamination in workspaces in Lower Manhattan, or whether other measures need to be taken to ensure that workspaces are not contaminated with WTC dust. 53 Report No. 2003-P-00012 Agency and New York City Comments and OIG Evaluation The Agency disagreed with the recommendations presented in this Chapter. The Agency responded that EPA’s indoor cleanup program was sufficient and that EPA studies and data indicated a more widespread cleanup program is not warranted. Because asbestos is a carcinogen with no commonly accepted safe level of exposure, and approximately 18,000 residential units in Lower Manhattan have not been tested or cleaned through the indoor residential program, we continue to believe our recommendations are warranted to assure adequate health protection for residents in Lower Manhattan. The Agency’s complete written response to our draft report and our detailed evaluation of that response are contained in Appendices Q and R, respectively. New York City’s response provided some technical clarifications which we made. New York City’s response to our draft report excerpts is provided in Appendix S. 54 Report No. 2003-P-00012 EPA Should Continue Efforts to Improve Contingency Planning The events of September 11 represented an attack on the U.S. mainland not previously experienced in this country’s history. The response to this tragedy was trying and difficult for all parties involved, including environmental professionals. Many of the persons we interviewed spoke highly of the response of EPA and its employees. Still, lessons were learned from the September 11 response that can be used to improve the Agency’s ability to respond to future disasters. The primary lessons learned from our evaluation relate to:
An overriding lesson learned was that EPA needs to be prepared to assert its opinion and judgment on matters that impact human health and the environment. Although many organizations were involved in addressing air quality concerns resulting from the WTC collapse, subsequent events have demonstrated that, ultimately, the public, Congress, and others expect EPA to monitor and resolve environmental issues. This is the case even when EPA may not have the overall responsibility to resolve these issues or the necessary resources to address them. EPA and several non-EPA groups and individuals prepared “lessons learned” reports on the government’s response to environmental issues resulting from September 11. We generally agree with the recommendations made in these reports. A summary on the previous lessons learned areas follows in Table 7-1. Further details on the lessons learned as part of both EPA and non-EPA reviews are in Appendix N. 55 Report No. 2003-P-00012 Table 7-1: Previous Lessons Learned Reviews
In September 2002, EPA issued its “Strategic Plan for Homeland Security,” which outlines the Agency’s plan for meeting its homeland security responsibilities. This Strategic Plan includes many proposed actions recommended in EPA’s February 2002 Lessons Learned report. The goals of the plan are grouped under four major mission areas:
The second and third mission areas – “Preparedness, Response, and Recovery” and “Communication and Information” – are particularly relevant to the issues 56 Report No. 2003-P-00012 discussed in this report. [17] Within these two major areas, the Homeland Security plan lists several actions that were recommended in the February 2002 Lessons Learned Report as well as issues identified in this report. OIG Observations for Improving Emergency Response Observations developed by our evaluation, as well as any Agency actions already underway to address these observations, are summarized in Table 7-2, and discussed in detail in the sections that follow. Table 7-2: Summary of OIG Observations
EPA has many years experience in responding to environmental emergencies and has established policies and procedures to deal with such emergencies. EPA’s Lessons Learned Report identified issues related to contingency planning and made recommendations for improvements in this area. Additionally, EPA’s Homeland Security strategy includes actions to address this area. Notably, the Agency has started efforts to upgrade the National Incident Coordination Team, which coordinates EPA’s response to large-scale emergencies. The events of September 11 demonstrate the following areas where the Agency’s emergency response mechanisms can be improved. _______________ 17 OIG has ongoing and planned work to evaluate EPA’s efforts related to the other major homeland security missions not addressed in this report. 57 Report No. 2003-P-00012 Environmental Threats from Potential Terrorist Attacks Need to Be Assessed It is understandable that the government and others were not fully prepared for what happened on September 11. Now that the country has experienced such an attack and lives under the threat of future attacks, it is important that the Agency anticipate and plan for different disaster scenarios. To the extent that EPA can anticipate various scenarios and plan for the type of environmental response needed before a disaster strikes, the Agency’s response efforts can be more focused on appropriate implementation and avoid making interpretative, technical, and policy-setting decisions with potential public health implications during the stressful and time-demanding circumstances created by an emergency. The experience of September 11 has provided the Agency with considerable information on what to expect of a large-scale disaster involving office and multi- family residential buildings in a densely populated urban environment. However, disasters involving other scenarios, other types of targets, and other locations may present different challenges. For example, New York City has significant emergency response and environmental resources - other cities may not and may require more assistance from EPA. In addition, EPA Region 2’s office was located within New York City and close to the disaster site, and EPA’s national Environmental Response Team was located in nearby Edison, New Jersey, approximately 30 miles away. This was important, because air travel was curtailed for several days after the attacks. EPA may not be as closely located to the next disaster. Disasters in different parts of the country could present different, perhaps greater, environmental exposures than at WTC. EPA researchers told us the tall buildings in New York City combined to create a “chimney effect” that helped to push air and pollutants upward and away from street level. Winds also helped disperse and dilute WTC airborne emissions, and rain during the first week helped alleviate dusty conditions. If a similar disaster were to strike in a city with different geography and weather patterns, a more serious exposure scenario could develop. Accordingly, EPA should work with the Department of Homeland Security and other agencies to share information on high-risk targets and areas, and develop plans for responding to an emergency situation in those areas. These plans should address the different scenarios anticipated from a disaster involving these targets and how EPA, other Federal, and the appropriate State and local agencies should respond to these different scenarios. 58 Report No. 2003-P-00012 Roles and Responsibilities Within EPA Need to Be Delineated EPA needs to delineate roles and responsibilities for its various programs offices when responding to emergencies, including how these roles and responsibilities fit within the incident command structure. Despite the commendable actions of many EPA personnel, the Agency should outline roles and responsibilities for its program offices beforehand to provide a more efficient and coordinated response to future disasters. For example, within 3 days of the disaster, EPA officials within the Office of Radiation and Indoor Air and the Office of Air Quality and Planning Standards had developed a web site with such captions as “Protecting Yourself from Asbestos Exposure,” “Health Effects of Dust and Smoke,” and “Strategies for Clean Up Inside Residences and Businesses.” However, this web site was not activated and made available to the general public. One EPA official told us there was an overwhelming amount of activity going on and that this information probably “got lost in the fray.” EPA Region 2 officials could not recall why the web site was not activated. Also, although EPA’s National Exposure Research Laboratory team made it to New York on September 16 to help implement an ambient monitoring network, they were unable to gain access to the site and start monitoring until September 21. The Laboratory’s monitoring team’s abilities were especially needed since they had air monitoring equipment that could run on both electrical and battery power, and they had airborne particulate matter monitors. In its lessons learned report, EPA Region 2 recommended that the Region identify a team of dedicated people who will respond in the event of a new crisis. In our opinion, other EPA regions should follow Region 2’s lead and identify specific areas of expertise that may be needed in the event of an emergency, and assemble teams of experts that can be mobilized to quickly provide this support. These areas may include specialized sampling techniques, exposure modeling and assessment, and risk assessment. Also, EPA Headquarters should develop national teams to support or augment Regional response when needed, including guidelines for determining when a response should be elevated to a national level. Roles and Responsibilities With Outside Agencies Need to Be Delineated A response to an event the size of the WTC incident requires the efforts and coordination of numerous government organizations, including Federal, State, and local governments. Our discussions with EPA and non-EPA officials, as well as WTC “lessons learned” reports from other organizations, indicated that there were overlapping and sometimes confusing roles and responsibilities for the various responding organizations. For example, early in the response, various agencies were conducting numerous sampling efforts. Particularly for asbestos, different 59 Report No. 2003-P-00012 sampling methods were being used with the results being reported in different metrics, which made the results more difficult to interpret. A senior New York City Office of Emergency Management official told us that roles and responsibilities of the Federal, State, and local agencies in responding to a disaster were unclear on September 11, 2001, and were still unclear when we met with him during the summer of 2002. EPA has addressed coordination with other organizations in both its Headquarters and Region 2 lessons learned reports. For example, the Headquarters Report recommended that EPA collaborate with OSHA and the Department of Health and Human Services to clarify the Agency’s role in protecting the health and safety of responders, and that EPA coordinate with Department of Homeland Security to develop a coordination strategy for all responders during national emergencies. Region 2 management and staff recommended that their Region clearly identify scope and boundaries of their work in an emergency; and educate EPA and other Federal and State officials about the scope, boundaries and authorities of the various emergency response plans and systems. We agree with these recommendations. These coordination efforts should also take place in all EPA regions and include FEMA, and should address likely sources of funding for these activities. Risk Assessment and Characterization The WTC disaster pointed to the need for better risk assessment and characterization procedures and tools for addressing the types of environmental concerns resulting from large-scale disasters. A significant challenge encountered by EPA and other organizations was how to characterize health risks to the public in the absence of health-based benchmarks. The need for consistent sampling protocols and special monitoring requirements was also demonstrated. Health-Based Benchmarks Needed Government entities, such as EPA, OSHA, ATSDR, and NIOSH, have developed guidelines for many of the contaminants found in Lower Manhattan. However, existing health benchmarks were not applicable to exposures experienced by the general public in Lower Manhattan. Many of the benchmarks available at that time to assess the exposure risks for contaminants found in the ambient air were: occupational standards based on an 8-hour-per-day exposure; guidelines based on long-term exposures; or standards, such as those for asbestos, that were not health based. Details on some of these issues are in Chapter 2. OSHA and NIOSH have developed occupational standards to protect industrial workers from pollutant exposures, but these standards are based on an 8-hour-a- day exposure. In general, these standards were not applicable to characterizing risks for residents who experienced exposures greater than 8 hours a day in indoor 60 Report No. 2003-P-00012 and outdoor settings. Some of the screening levels developed to assess the sub-chronic risks from the contaminants created by the WTC collapse were developed by adjusting emergency removal guidelines listed in EPA’s Hazard Evaluation Handbook to take into account shorter exposure periods. These guidelines are based on a 30-year exposure period and correspond to a 1-in-10,000 increased lifetime cancer risk for carcinogens. Further, some of the benchmarks used to assess air quality and bulk dust in Lower Manhattan were criteria- or condition-based standards and not health-based standards. For example, the benchmark used to assess asbestos risk from WTC dust was developed to determine when asbestos containing material was subject to demolition and renovation regulations. For future disasters, health benchmarks are needed to address the types of exposures experienced at the WTC site, which included:
Details on each of the above benchmarks are in Appendix O. We recognize that it is not possible to anticipate all the scenarios and develop standards that address all possible pollutants that may result from a disaster. Thus, we believe an agreed-upon framework for quickly developing additional guidelines and benchmarks in an emergency situation is needed. This process could include a panel of scientific experts that would be available in an emergency to analyze the available risk data and establish appropriate health-based benchmarks for the pollutants of concern. As discussed above, a multi-agency workgroup developed health-related benchmarks for six pollutants of concern related to indoor environment contamination from the WTC collapse that underwent peer review in October 2002. We believe the Agency should expand on these efforts to identify benchmarks for other pollutants of concern and for outdoor and indoor exposures based on threat assessments discussed earlier in this chapter. Related to this effort, EPA should collect information on background levels (i.e., pollutant concentrations under normal conditions), to properly assess the impact that a disaster has on the concentration of these pollutants of concern in the environment. 61 Report No. 2003-P-00012 Sampling and Data Collection Protocols Needed EPA, other government organizations, and non-governmental organizations undertook extensive monitoring efforts in the months following September 11. Extensive sampling was done around the work zone to monitor conditions for first responders. To assess ambient conditions for the general public, EPA established an ambient monitoring network in coordination with New York City and New York State officials. EPA also developed a draft Quality Assurance Project Plan for the WTC ambient monitoring network; however, the plan was not finalized. A comprehensive Quality Assurance Project Plan outlines the objectives of the monitoring, identifies the monitoring and sampling methodologies, identifies the siting of monitors, and outlines monitoring exit strategies. In essence, the Plan helps to ensure that sufficient data is collected of adequate quality for the decisions to be made. The Quality Assurance Project Plan should also address the format and means of transmitting data. In the WTC response, various government agencies collected a large amount of environmental data for Lower Manhattan in the months following September 11. The Office of Environmental Information maintains the New York City Response Monitoring Data Retrieval database, which stores the monitoring data collected by the various Federal, State, and City environmental agencies involved in the response. According to a report prepared by an EPA contractor that analyzed trends in the data, the database contained 263,000 monitoring results for 605 contaminants through April 24, 2002. Because the data came in different formats, consistent sampling, monitoring, and quality assurance information was not provided for each of the pollutants monitored, and in many instances this data was not provided. Our review of information in the database confirmed the trends noted by the contractor. Providing standardized guidance for the organizations reporting data to EPA would improve the consistency of the data. A complete data set would make future assessments of the data easier to complete. Both EPA Region 2 and EPA Headquarters’ Lessons Learned reports made recommendations to improve data collection. The Region 2 Lessons Learned report recommended that all organizations submit data in an electronic format, and standardized formats should be used as much as possible. The report also recommended that easy-to- understand context and explanations be provided for the data, to allow data and risk assessments to be released to the public more quickly. EPA’s Office of Environmental Information has created a standardized template for future responses by making a generic shell of the New York City Monitoring Database. This Office is also exploring longer-term improvements. With regard to WTC data, Region 2 officials have been working to improve the data in the “NYC Response” database by requesting that organizations perform a quality assurance review of the data they submitted to EPA. Once this process is 62 Report No. 2003-P-00012 completed, the data will become available to the public on a CD-ROM. We agree that EPA should continue to explore long-term improvements for data collection. Monitoring Capabilities Need to Be Increased The amount of monitoring data for pollutants other than asbestos was limited in the first few weeks following September 11. In the beginning, monitoring efforts were hampered by several factors. There were difficulties associated with getting access and security, power supply sources, equipment availability, and analytical capacity. One environmental monitoring expert who participated in environmental sampling and analysis after the WTC collapse suggested that emergency response monitors must be improved and recommended that lightweight and manageable battery operated air samplers be developed that are able to measure a wide range of particles and gaseous substances. In the case of a major disaster that causes a significant dispersion of particulates, the levels of TSP can be a concern, particularly in regard to acute respiratory symptoms. However, in the WTC response, these particles were not monitored because of a lack of TSP monitors. The availability of TSP monitors has decreased over time as EPA’s National Ambient Air Quality Standards program has shifted its focus from measuring TSP to measuring smaller particles. While health studies support measuring smaller particles from the standpoint of the National Ambient Air Quality Standards program, experts told us that it is useful to measure the levels of TSP in a disaster to determine potential short-term or acute health effects. EPA Headquarters’ Lessons Learned Report addressed equipment needs and recommended that EPA clearly identify such needs. In addition, the Office of Air Quality and Planning Standards acquired funding for a Mobile Rapid Response Laboratory to collect data quickly in emergency situations and transmit data to a central database via satellite. The Office of Air Quality and Planning Standards plans to establish two such mobile laboratories. The collapse of the WTC towers disrupted normal communication infrastructures, yet required that difficult decisions about the condition of the environment be made quickly and under extreme stress. Under these conditions, EPA made extraordinary efforts to successfully assemble an extensive amount of information on its web site and otherwise communicate to the public. Despite these efforts, the information EPA communicated was in some cases inconsistent with prior Agency positions, inconsistent with other communications regarding the WTC disaster, or incomplete. Some of these communication problems may have been avoided if the Agency had updated policies and procedures in place for communicating to the public and had followed existing risk communication 63 Report No. 2003-P-00012 guidelines established for the Superfund program. Based on its experience with the WTC response and the subsequent anthrax contamination responses, EPA has initiated various actions to improve its communication practices. Better Communication Policies, Procedures, and Guidance Needed Officials from EPA’s OCEMR and its successor office, the Office of Public Affairs, in Washington, D.C., were not able to provide us with current written policies or procedures for communicating with the public. Although not established as official Agency communication policy, EPA’s Superfund program has issued several guidance documents regarding risk communication. EPA’s risk communication principles and recommended practices are contained in EPA’s Superfund Community Involvement Handbook. This Handbook identifies the “Seven Cardinal Rules of Risk Communication,” presented in Chapter 2. As explained in the following, EPA’s risk communications did not consistently adhere to the principles and guidelines discussed in its Superfund guidance. Risk Communications Need to Acknowledge Uncertainties EPA’s Superfund Community Involvement Handbook specifically discusses uncertainties (“Be willing to discuss uncertainties”), and the fourth rule states: If you do not know an answer or are uncertain, acknowledge it and respond with the answer as soon as possible. Do not hesitate to admit mistakes or disclose risk information. Try to share more information not less; otherwise, people may think you are hiding something. As detailed previously in this report, EPA’s statement that the air was safe to breathe was not qualified (except for rescue and cleanup personnel at Ground Zero). Further, EPA’s press releases did not discuss any of the uncertainties associated with this statement. Dr. Peter Sandman, founder of the Environmental Communication Research Program at Rutgers University, provided 26 recommendations for risk communication. These include that one should “acknowledge uncertainty” and urged “never using the word ‘safe’ without qualifying it.” Procedures Needed to Ensure Consistency in Communications EPA communications after the WTC catastrophe sometimes gave conflicting information in regard to the same issue or were inconsistent with prior Agency positions. Specifically, information provided orally about cleaning of indoor spaces was not consistent with the messages given in Agency press releases. 64 Report No. 2003-P-00012 Also, EPA communications about the risk from asbestos were not entirely consistent with prior Agency public positions regarding asbestos risk. EPA’s communications during the WTC crisis – that the general public did not need to be concerned about short-term exposure to WTC asbestos – were inconsistent with the Agency’s prior position that all asbestos exposure is hazardous to human health. EPA’s historical position, as detailed in the Federal Register, has been that: . . . short-term occupational exposures, have also been shown to increase the risk of lung cancer and mesothelioma. In addition, there are many documented cases of mesothelioma linked to extremely brief exposure to high concentrations of asbestos or long-term exposure to low concentrations. . . . EPA has concluded that it is prudent to treat all fiber types as having equivalent biological activity...Available evidence supports the conclusion that there is no safe level of exposure to asbestos. (April 25, 1986 Federal Register Volume 51, page 15722) However, EPA’s position in its September 13, 2001, press release was that the public did not need to be concerned about short-term exposure to WTC asbestos. The confusion of some residents may have been reflected at a May 8, 2002, press conference, when the questioner quoted EPA’s 1986 position and asked the Region 2 Administrator: Available evidence supports the conclusion that there is no safe level for exposure to asbestos. So what science are you citing that there is a safe level? The EPA Region 2 Administrator replied: We are talking about very short term exposure to quantities of [unintelligible word] that - we know exactly that these buildings came down and they contained asbestos. There are other places in the country perhaps where people have been exposed over long periods of time - based on using substances containing asbestos - and breathing them - as part of their household. We know this was a one time - you know buildings came down, and that is what needs to be cleaned up so there is not that risk of long term exposure. The research community has not reached consensus on the relative risk to human health from exposure to different types and sizes of asbestos, and EPA’s approach has been to not distinguish between fiber types and sizes when characterizing the risk from asbestos exposure. Many experts and studies support the general message EPA conveyed about asbestos exposure and risk after the WTC |
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