EPA'S RESPONSE TO THE WORLD TRADE CENTER COLLAPSE:  CHALLENGES, SUCCESSES, AND AREAS FOR IMPROVEMENT

Appendix R

OIG Evaluation of EPA's Response to the Draft Report

Transmittal Memorandum

Note 1 -- We believe the report's findings, conclusions, and recommendations properly consider the unprecedented circumstances in which the response to the WTC tragedy was carried out. For instance, we point out the unprecedented nature of these events in the first line of the Executive Summary and the first line of Chapter 1. We do not believe that a response to such a tragedy can be conducted under a business as usual attitude. However, an emergency response should not preclude the Agency from following previously established guidance and practices regarding public safety and protection from hazardous substances conceived and designed to be applied in times of crisis. This position is consistent with the intent of EPA's Guidelines for Catastrophic Emergency Situations Involving Asbestos issued in 1992. These guidelines were issued after emergency responses to three incidents in 1989 focused attention on the need to consider asbestos along with other emergency response activities. Additionally, although the initial emergency response was carried out under trying conditions, as time passed the crisis nature of the response subsided and the Agency had the opportunity to consider its actions carefully before continuing its response efforts. For example, decisions regarding the approach to addressing indoor contamination evolved over time, after extensive deliberations, and well after the initial emergency response had subsided. We also note that, except for the recommendations in Chapter 6, the Agency agreed with the recommendations in five other chapters of the report, which does not suggest that we misunderstood the circumstances that the Nation, EPA, or the City faced following the disaster.

Note 2 -- We agree that the Agency should be proud of the response of its men and women in the aftermath of the WTC attacks and collapse. We also agree that the Agency's response was made under extremely trying circumstances as detailed in Chapter 1 of the report. The findings, conclusions, and recommendations in this report are in no manner intended to disparage the valiant contributions of EPA personnel, or those of any other responding organization.

Note 3 -- We agree with the need for coordinated federal efforts and the concept of centralized communications during a time of national emergency. In the report we recommend that EPA develop emergency communications policy and procedures which are consistent with the "Seven Cardinal Rules of Risk Communication," the fifth of which is to "coordinate and collaborate with other credible sources."

We do not believe the report "goes to great length to erroneously criticize" CEQ's efforts "to coordinate health and safety communications." In accordance with the first assignment objective, the report appropriately examines the analytical basis for EPA's major public communications regarding air quality. To the extent that reassuring words were added to EPA's draft press release and cautionary words were deleted, it

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is important to understand the basis for such changes in the Agency's risk communications. The report also provides the former EPA OCEMR Associate Administrator's explanation for why EPA's press releases did not discuss health effects or contain a recommendation that residents obtain professional cleaning. Additionally, as noted by the former EPA Chief of Staff, factors other than protecting human health and the environment entered into the determinations of the information that would be communicated to the public, including national security considerations and the desire to re-open Wall Street.

Note 4 -- We agree that EPA made its data available to the public. However, based on the documentation we reviewed and our discussions with numerous environmental experts, both within and outside of EPA, we do not agree that the Agency's statement on September 18, 2001 that the air was safe to breathe reflected the Agency's best professional advice. In contrast, based on the circumstances outlined in Chapter 2 of the report, it appeared that EPA's best professional advice was overruled when relaying information to the public in the weeks immediately following the disaster.

Note 5 -- We applaud EPA's efforts to evaluate its response and implement changes. We believe the report sufficiently acknowledges EPA's efforts to implement its "lessons learned." The draft report's Executive Summary acknowledges EPA's "lessons learned" efforts and highlights specific actions the Agency initiated. In addition, Chapter 7 of the report discusses EPA's "lessons learned" efforts in great detail.

Note 6 -- We do not believe the report "is flawed in its lack of recognition" of the issues discussed. In regard to the absence of a long-term health threat, the Agency did not have a sound basis for reaching this conclusion at the time for the numerous reasons detailed in the report. Further, as noted in the report, the position that EPA took regarding WTC is inconsistent with the Agency's historical position that there is no safe level of asbestos.

In regard to the comment about the Agency advising people who were experiencing acute health problems to see their physician, no supporting documentation has been identified which shows that EPA instructed residents to see their physicians. We also provided agency officials with the opportunity to provide us with documentation which supported specific statements, but none has been provided to date.

In regard to EPA discussing acute health problems, we reviewed extensive information on EPA's risk communications, including all of the documents and videocassettes which were provided by Region 2 and EPA's Office of Public Affairs. We agree there were instances where documentation indicated agency spokespersons discussed acute health problems. However, as detailed in the draft report, EPA's press releases generally did not discuss potential acute health problems or the need to see a physician (except for rescue and cleanup workers at Ground Zero). The words "physician," "doctor," "acute," "symptoms," and "sensitive," do not appear in any of EPA's WTC press releases. Considering the totality of all the information we reviewed, it is our opinion that EPA did not communicate a clear, or consistent message on this subject. We agree that EPA advised rescue and cleanup workers to

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take safety precautions. This agreement is detailed on page 9 of the draft report and illustrated in Appendix P.

We do not agree that EPA "emphasized" the need for professional cleaning because this concept was not discussed in EPA's press releases. According to the OCEMR Associate Administrator, a recommendation to obtain professional cleaning was deleted from an EPA press release by a CEQ official. As detailed in the draft report, EPA's press releases referred the public to a New York City Department of Health web site which recommended that people clean their own residences and businesses using wet rags, wet mops, and HEPA vacuums.

Note 7 -- We do not believe that "The Report erroneously focuses" on five early Agency press releases. We reviewed many different types of information from many different sources including videocassettes which were provided by Region 2. We made extensive efforts to locate all relevant records. For example, by contacting the Administrator's Press Secretary and Scheduling Director, we were able to determine the date of a videotaped newscast which showed the Administrator advising the public orally about obtaining professional cleaning on October 26, 2001. Similarly, we worked closely with Region 2 officials and agreed with their analysis that EPA's web site recommended professional cleaning at least as early as December 11, 2001. In summary, although EPA's subsequent communications sometimes added information or clarification to the message presented in the press releases, the Agency's overall message of reassurance about long-term health impacts did not change.

In regard to the comment in the response to the draft report about EPA's "massive outreach program," we note, as detailed in the draft report, that a NYCDOH study, other lessons learned reports, and testimony provided at various hearings indicated that the public did not receive adequate air quality information and that individuals cleaned their residences without using proper procedures or personal protection.

Note 8 -- We agree there were no health-based standards for many of the pollutants encountered in the aftermath of the WTC attacks, and the report does not intend to find fault with EPA or any other government organization for not having developed those benchmarks beforehand. However, we do not agree with using certain criteria-based benchmarks -- particularly the NESHAP asbestos- containing material definition of one percent asbestos -- as health-related benchmarks when environmental professionals clearly acknowledge that this standard is not protective of health.

Note 9 -- The Agency is to be commended for its proactive approach to analyzing its response to the WTC collapse and initiating improvements to its emergency response capabilities. We disagree with the Agency's comment that this report "trivializes both the horrendous event that occurred and the extraordinary efforts of EPA and other responders." The primary objective of the report is to ensure that, if such a tragedy were to happen again; the public and emergency responders impacted by the disaster would receive the best available advice, protection, and assistance that the Government can provide.

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General Observations

Note 10 -- We agree that the Agency's response to the WTC collapse was unprecedented and enormous in terms of resources and human effort. Page 5 of the draft report acknowledged the many other activities -- in addition to the air quality related activities - -that EPA conducted in response to this tragedy.

Note 11 -- We agree that the Agency undertook extraordinary efforts to provide information to the public and we acknowledge that the documents we reviewed indicated EPA provided full disclosure of sampling results. However, in our opinion, the importance of Agency press releases should not be minimized. As detailed in the draft report, EPA press releases result from a deliberative process that should reflect the Agency's official position on significant issues. Press releases are made available to essentially all news media and may well be quoted or paraphrased in radio, television, and other forms of communication. In our opinion, the Agency could have provided more complete and more useful information in its press releases.

We also agree that future incidents may involve scenarios that cannot be anticipated. In order to address this possibility, the draft report recommends that EPA designate teams of Agency experts -- at both the National and Regional level -- who can be mobilized quickly to provide needed technical support during a response, and that the Agency develop expert panels that can be used to quickly develop health-related benchmarks in emergency situations.

Chapter 2

Note 12 -- We fully recognize the extraordinary circumstances that existed at the time the statement was made about the air being safe to breathe. However, for the reasons detailed in the draft report, there was insufficient information to support the statement made and the principle of acknowledging uncertainty was relevant.

We disagree with the assertion that EPA's statement about the air being safe to breathe would clearly be understood by New Yorkers as applying exclusively to asbestos. The press release sentence which preceded the subject statement asserts that New Yorkers are "not being exposed to excessive levels of asbestos or other harmful substances ..." The same press release also states that sample tests results are "below established levels of concern for asbestos, lead and volatile organic compounds."

Note 13 -- We agree that, to our knowledge, EPA never withheld data from the public, and the draft report makes this point (page 10). The draft report does not imply that it is "unusual" or "unexpected" for the Agency to coordinate with CEQ during a "catastrophic disaster." In such a situation we would expect EPA to coordinate with numerous government entities and any non- government entity that could provide needed services. However, we would expect EPA to remain fully committed to its

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mission of "protecting human health and the environment" during a catastrophic disaster. We understand that national security considerations or the desire to re-open Wall Street may affect certain communications. However, in our opinion, if such considerations cause EPA to omit or change statements that would otherwise have been made in its efforts to fulfill its mission, the Agency risks harm to its long term credibility as an authoritative source of health information for the public in times of crisis. EPA needs to acknowledge significant collaborations and, where necessary, qualify its communications appropriately. We agree with the goals of EPA's Homeland Security Strategic Plan which commit EPA to disseminating quality environmental information to all levels of government, industry and the public.

Chapter 3

Note 14 -- We agree that, from the beginning, EPA and other government entities provided advice to residents to cleanup indoor spaces using wet rags, wet mops, and HEPA vacuums. As detailed in the draft report, EPA's Administrator and various Agency spokespersons orally advised the public to obtain professional cleaning when the dust was in their residences was "more than minimal," "a heavy amount," etc. However, we note the Agency's web site referred readers to NYC guidance and that a NYCDOH press release reassured residents that it was "unnecessary to wear a mask" while cleaning indoor spaces, and if a HEPA filtration vacuum was not available, simply "wetting the dust down with water and removing it with rags and mops is recommended."

In regard to potential exposures to asbestos and other contaminants, we note that a study of immigrant workers used to clean indoor space contaminated with WTC dust disclosed that these workers were not provided with personal protective equipment. The study reported that these workers reported health symptoms including coughing, sore throat, nasal congestion, chest tightness, headaches, fatigue, dizziness, and sleep disturbances that worsened after September 11, 2001. Further, a NYCDOH survey conducted in October 2001 found that the majority of residents polled had not followed the recommended cleaning procedures of using wet rags and HEPA vacuums. With respect, to the effectiveness of the cleaning studies, we note that EPA's Confirmation Cleaning Study report dated May 2003 found that:

...one to three cleanings were necessary to reduce contamination levels to below health-based benchmarks, and the number of cleanings required generally correlated with the levels of contamination initially identified in the units.

We continue to believe unprotected workers and residents may have experienced unnecessary exposures to asbestos and other pollutants.

Note 15 -- We agree EPA repeatedly stated that workers at Ground Zero should wear respirators, and that the Agency raised these concerns to local officials as discussed in Appendix L of the report. However, EPA's advice that workers wear respirators was directed to Ground Zero workers at the debris pile, and not to workers who cleaned contaminated indoor spaces outside the perimeter of Ground Zero. In regard to EPA's statements

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that they repeatedly advised sensitive sub-populations and people experiencing acute symptoms to consult a physician, we note that these warnings were not presented in EPA's press releases. We attempted to verify the extent to which EPA advised these other groups through other forms of communication. For example, we reviewed briefing notes prepared for public meetings that EPA [sic]. These briefing notes showed that EPA officials intended to discuss sensitive populations at two public meetings in October 2001. We also reviewed newspaper and other news articles to determine when EPA publicly provided such advice. Based on the evidence EPA provided to us, and our own independent research, we were not able to conclude that EPA "... repeatedly advised anyone with acute symptoms to consult with their physicians ..."

Chapter 4

Note 16 -- We acknowledge the difficulty in implementing NESHAP work practices in the aftermath of the WTC collapse and agree that these work practices should not be implemented to the detriment of rescue operations in any emergency situation. However, even in the aftermath of an emergency, appropriate measures should be taken to the extent practical to reduce the exposure of emergency responders, clean-up crews, and the surrounding public to asbestos emissions.

Note 17 -- We agree that EPA conducted many activities to support efforts to alert Ground Zero workers to health-related issues, and we discuss these actions in Appendix L of the report.

Note 18 -- EPA notes that the public sometimes wants information that is not scientifically available, or is not available quickly. We agree that this may sometimes be the case. EPA guidance in discussing the 4th rule of the "The Seven Cardinal Rule of Risk Communication" states: "If you do not know an answer or are uncertain, acknowledge it and respond with the answer as soon as possible."

Chapter 6

Note 19 -- The Agency states that there are many residential and commercial buildings below Canal Street, and that a cleanup program including all of them would be a monumental undertaking that EPA studies and data indicate is not necessary. We agree that this would require a significant effort. However, the former EPA Administrator stated in September 2001 that the President made it to clear to spare no expense and to do everything needed to make sure the people of New York City were safe as far as the environment was concerned.

We agree that the vast amount of outdoor dust and debris has been removed, and thus exterior sources for contamination of indoor spaces have been significantly reduced. However, any indoor spaces contaminated with WTC dust that have not been cleaned using proper techniques will likely remain contaminated. The Agency notes that in

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95% of the residences that were cleaned and tested or cleaned only, the asbestos readings were non-detect. It is encouraging that 95% were non-detect. However, it is not clear which sampling methods were used in obtaining these readings, what asbestos levels were present in the remaining 5 percent, and whether EPA believes possible asbestos contamination in 5 percent of the residences is acceptable. See note 24 for our comments regarding cleaning effectiveness.

Note 21 -- Concerning the use of aggressive sampling, we agree that the use of a leaf blower does not represent normal activity in a residence. Neither does the use of a leaf blower represent normal activity in a school room, although the AHERA standard requires its use for clearing a school room after an asbestos abatement. Under a standard asbestos cleaning, all items in a room would be cleaned thoroughly, even documents as was done when cleaning a courthouse in Titusville, FL. In a private residence, especially when cleaning is voluntary and the owner can refuse to have individual items touched, it is extremely difficult to ensure that each item is cleaned of every microscopic asbestos fiber, yet this degree of cleaning should be the intent of the cleanup. Use of a blower prior to aggressive sampling serves to stir up the air, re-entrain dust and fibers in the air stream, and allow negative air filtration equipment to trap fibers that have been missed in the wet cleaning process or skipped entirely. It thus can be as much a cleaning procedure as a sampling procedure. We believe it is a necessary adjunct to the type of cleaning performed in NYC.

Note 22 -- We accept EPA's statement that Agency officials qualitatively evaluated the potential for health risks beyond the current boundaries established for the residential cleanup. However, if a future disaster were to occur, we believe the boundaries of any government-organized cleanup should be based on a systematic, quantitative approach to determining the extent of contamination.

Note 23 -- EPA issued a revised "World Trade Center Indoor Environment Assessment: Selecting Contaminants of Potential Concern and Setting Health-Based Benchmarks," as well as a "Response to Peer Review Comments on the Report." We note that both these documents cite the "World Trade Center Background Study Report" and the "Interim Final WTC Residential Confirmation Cleaning Study" which were issued in April and May 2003, respectively. Neither of these documents were available when the TERA panel peer reviewed the original COPC document in  October 2002. In light of the significant, detailed comments that the peer review panel had on the original report, the detailed responses made in EPA's response document, and the fact that additional information is now available that was not available during the first peer review, we continue to believe it is appropriate that EPA re-submit the revised report, with newly issued supporting documentation, for peer review.

Note 24 -- EPA states the belief that "... health-based asbestos-in-air clearance testing is effective in reducing the potential for risk related to [other] WTC contaminants." We note that 82% of the residential units re-cleaned during the Cleaning Study [Interim Final WTC Residential Confirmation Cleaning Study, Vol. i, pp.113-114] had to be re-cleaned because the sampling filters were too clogged with dust to be analyzed. While we agree with the decision to re-clean residences under this circumstance, we

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also interpret this to mean that, after cleaning, the units were still too dusty to pass the clearance test over 80 percent of the time. This is evidence that the cleaning process, although conducted under close EPA oversight, was often not successful. We had no evidence that this cleaning process would be more successful under the oversight of others, nor that the risks from exposure to other contaminants would be significantly reduced when the residence passes the asbestos clearance test.

Note 25 -- Our recommendation applies to the interior building system in buildings with central heating, ventilation, and air conditioning (HVAC), composed of furnace/cooling coils and condenser, plenum, filtration system, supply ducts, and return ducts or return open air plenums. We continue to believe that these buildings should be treated and cleaned as an entire building system rather than as individual apartments because of the high likelihood that uncleaned subparts of the system will re-contaminate the entire system when the system is re-energized after cleaning of registers/ducts in a single or small group of apartments. We do not believe the absence of "widespread exceedences" provides sufficient assurances that public health is protected. EPA's own regulations state that asbestos is a known human carcinogen with no known safe level of exposure.

Note 26 -- As indicated on page 9 of its response, EPA indicates that it has coordinated with OSHA throughout the indoor cleaning program, and that OSHA is prepared to address worker complaints. While we commend EPA and OSHA for coordinating on this issue, we continue to believe EPA, OSHA, and FEMA should assess the need for a work space cleaning program and formally come to an agreement as to whether or not work spaces should be addressed pro-actively by a cleaning program.

Chapter 7

Note 27 -- Based on the events that unfolded after September 11, 2001 it is clear that the public looks to EPA for its advice and opinions on issues related to the environment. We expect that the public and the Department of Homeland Security will continue to look to EPA for its professional advice and judgment on matters related to the environment.

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