EAST PALESTINE, OHIO – September 3, 2024 – The Village of East Palestine contracted with Mission Critical Partners to conduct an unbiased After-Action Review (AAR) following the Norfolk Southern train derailment that occurred on February 3, 2023. An AAR is a qualitative, structured review of the actions taken in response to an actual public health event as a means of identifying and documenting best practices, gaps and lessons. Performing an AAR is highly encouraged and constitutes best practices, a useful tool in identifying immediate and longer-term corrective actions for future responses. The culmination of the AAR and Improvement Plan is prepared by Mission Critical Partners. This plan was presented to the public at the East Palestine Village Council Meeting on August 29th at 6:00 p.m.
Project Overview
Mission Critical Partners collected and reviewed all available public data and information sources and conducted both individual interviews and focus-group sessions with stakeholders over a five-month span. Stakeholders included elected and appointed officials, field responders, county, state and federal officials, as well as community members. The study looked at the four common emergency management phases – preparedness, response, recovery and mitigation. The AAR focus areas of each phase included communications, incident command, liaison efforts, interactions with federal, state, regional and private sector agencies, interstate mutual aid, and interpersonal skills and personal performance.
Statements
Bonnie Maney, Enterprise Client & Operations Domain Manager, Mission Critical Partners noted, “It is relatively easy to suggest alternative courses of action after a tragic event when in a controlled environment and as more information is brought to light. The things in this review would have taxed any center and any municipality of this size. What you did in the moment, under those extraordinary, extraordinary circumstances and that there was no loss of life, is remarkable.”
The After-Action Review noted, “Despite not having the available staff to handle public information duties directly, public information was given priority from the onset of the incident.”
Assessment Areas
The study covered seven functional areas involved in the response and provided key findings for each area noted:
- Communications & Public Safety Answering Point (PSAP) Operations
- Fire and EMS
- Law Enforcement
- Unified Command
- Emergency Management Agency (EMA)
Public Information Officers (PIO) - Environmental Protection Agency (EPA)
Top Findings Summary
Coordination
- Unstructured unified command
- Uncoordinated mutual aid requests and responses
- Safety-focused coordination with the EPA was a benefit
- Teamwork and dedication from staff were strengths
Planning
- Real-time unplanned and unscripted decisions by dispatch and other first responders
- Large-scale, multi-jurisdictional fire/EMS response was not pre-planned
- Limited staffing and resources (e.g., PSAP single dispatcher)
- Real-time problem solving was a strength
Systems Equipment
- Poor radio coverage
- Lack of interoperability
- Channel saturation and lack of control
- Emergency lines overwhelmed by inbound calls from community after evacuation notice went public
Training
- Dispatch and field responders with minimal or no training on large-scale incidents of this nature
- EMA training, preparation, and experience was an asset
- Low attendance, not mandatory and attendance thresholds
- Training exercise for a train derailment with hazardous materials that was widely attended by first responders four months prior to the derailment provided local responders with valuable knowledge that was put to practical use during derailment
Improvement Plan
A total of 39 recommendations were made in the following four areas: Coordination,
Planning, Systems & Equipment and Training.
Next Steps
The Village of East Palestine and its respective departments are working diligently to address the improvement areas identified in the report and to better prepare for future incidents that may require a swift emergency response. Collaboration is key because of the geographical location of East Palestine and the limited resources in rural areas, but the Village is committed to doing whatever is necessary to learn and grow from this unfortunately incident. While funding to hire more personnel, conduct training and upgrade the technology infrastructure will be an ongoing challenge, the Village is y exploring avenues to obtain funding for these efforts.
Improvements in Process or Completed
Chief Keith Drabick reported that the Village of East Palestine Fire/EMS has already worked through many of the recommendations provided and has completed the following:
- Completed Recommended Training – NIMS ICS-300 & ICS-400
- Establishing Level 1 and 2 Staging
- Established a Box Alarm System
- Avenues for additional funding are being considered and pursued
Contact Information
For more information and a copy of the full report on the Village of East Palestine February 2023 Train Derailment After Action Review and Improvement Plan conducted by Mission Critical Partners, please contact info@eastpalestine-oh.gov.
About the Village of East Palestine
Founded in 1875, the Village of East Palestine is a close-knit community known for its rich history, friendly atmosphere, and commitment to progress. With a population of just under 5,000 residents, the Village of East Palestine offers a unique blend of small-town charm and modern conveniences, making it an ideal place to live, work, and visit. For more information, go to epohio.org.
About Mission Critical Partners (MCP)
Mission Critical Partners (MCP) is a leading provider of data integration, consulting, network, and cybersecurity solutions specializing in transforming mission-critical communications networks into integrated ecosystems that improve outcomes in the public safety, justice, healthcare, transportation, and utility markets. Our comprehensive experience and vendor-agnostic approach help us develop modernized solutions for our clients to maximize value and create optimal efficiency while mitigating risk. Additional information and career opportunities are available at MissionCriticalPartners.com.