San Mateo County Office of Emergency Services: Post-San Bruno Fire Self-Evaluation Issue | Background | Findings |

The Grand Jury finds that: The AA/CA Report was due on December 7, 2010. OES requested and received a thirty-day extension from the Coastal Region Office of CAL EMA; a final AA/AC report was filed on January 7, 2011.

The Grand Jury finds that: OES did not follow the recommended steps in the SMC “Operational Area” Emergency Operations Plan, EOC Guidebook and Checklists such as: conducting data gathering workshops to include key representatives of involved emergency response agencies; and the preparation/distribution of a draft AA/CA Report to the primary responders for review and approval.

The Grand Jury finds that: OES conducted a debriefing session on November 23, 2010 in preparation of the AA/CA Report.

The Grand Jury finds that: Representatives of San Bruno (police, fire, city management, emergency services) were neither invited nor included in the debriefing session held by OES on November 23, 2010.

The Grand Jury finds that: The AA/CA Report filed by OES was not distributed to representatives of San Bruno police, fire, city management, or emergency services.

The Grand Jury finds that: The San Mateo County “Operational Area” Emergency Operations Plan, EOC Guidebook and Checklists, which is currently in revision by OES, does not require a follow-up process to track progress and completion of improvement items.19

The Grand Jury finds that: The task of compiling the information gathered from email questionnaires and the November 2010 debriefing meeting for the AA/CA Report was assigned to OES personnel within the Sheriff’s Office.

The Grand Jury finds that: The OES Coordinator provided his superior with the final report for filing with the State and distribution to the County Manager’s Office, the County Communications Director, Supervisor Adrienne Tissier, Public Safety Communications, and members of the press who requested it.

The Grand Jury finds that: The final AA/CA Report was not widely distributed; several of the individuals listed as a point of contact in the Report were unaware that their names were assigned to specific issues or problem statements, nor were they aware of the issues or problems identified within the Report. SMC “Operational Area” Emergency Operations Plan, EOC Guidebook and Checklists, Joseph R. Horton, Jr., Section 3, Tab 2, March 2007 11

The Grand Jury finds that: According to the objectives and self-estimated completion dates on the AA/CA Report, the OES completed three of the 13 corrective items (items 9, 10, 12) on time.20

The Grand Jury finds that: According to the objectives and self-estimated completion dates identified in the AA/CA Report, the OES did not complete nine of the 13 corrective items (items 1, 2, 3, 4, 5, 6, 7, 8, 11) on time.21 Seven of those nine were still incomplete as of January 2012.

The Grand Jury finds that: According to the objectives and self-estimated completion dates identified in the AA/CA Report, the OES found corrective item 13 to be non-applicable because the Response Information Management System (RIMS) training is being replaced.

The Grand Jury finds that: The Primary EOC for the County is the Jury Assembly Room in the basement of the Hall of Justice in Redwood City, with the Alternate EOC located in the OES office on the 4th floor of the County Office Building at 555 County Center.

The Grand Jury finds that: The Jury Assembly Room has no dedicated EOC functionality or equipment; it has no OES electronics, it has few phone lines and limited cell phone coverage.

The Grand Jury finds that: The Jury Assembly Room is designated as the Primary EOC because it is the largest unclaimed (by other agencies) space in the Hall of Justice and can be emptied of civilians awaiting jury duty during regular business hours. With respect to the San Bruno Disaster and response by OES:

The Grand Jury finds that: A Joint Information Center (JIC) was not in place at the disaster site.

The Grand Jury finds that: The County Health Department requested portable radios to use after the immediate disaster phase of the San Bruno incident; the Information Services Department’s Radio Shop denied its request based on the requirements stated in the Trunked Radio Cache Guidelines.22

The Grand Jury finds that: The AA/CA Report recommended white status boards be purchased to use in the EOC. These boards have not been acquired as of February 2012 due to “budget constraints.” The cost of four status boards is approximately $3,200.

Cell phone coverage at the fire scene was overloaded and spotty. OES acknowledges widespread use of mobile phones for official business. The contact person identified in the AA/CA Report for Item 8 was unaware that it was his responsibility to address this issue. Attachment 1- After Action/Corrective Action Report - Potential Corrective Actions, January 7, 2011 21 Ibid. Trunked Cache Radio Guidelines, August 2007. 12

At the Red Cross shelter established at the Glenview site, each registered person was asked to sign a Red Cross statement outlining Red Cross’ commitment to keep information confidential. Restrictions in the Red Cross confidentiality statement prevented the release of identities of persons under Red Cross care, which in turn impeded public safety officers attempting to determine if all residents had evacuated the disaster area. Conclusions The Grand Jury concludes that:

As a result, the County was required to complete and submit to the State an After Action/Corrective Action Report (AA/CA Report) to document response activities, identify problems/successes during the response effort, and define action plans for implementing improvements. The AA/CA Report identified 13 items for improvement.2 The Grand Jury 1 After Action/Corrective Action Report, City of San Bruno EOC Preliminary Report, December 27, 2010. The i nfrastructure damage estimate was set in a negotiated trust fund between San Bruno and Pacific Gas & Electric Co., the operator of the pipeline. Those monies will go to rebuild streets, sewer lines and other municipal property damaged in the explosion. See, San Francisco Chronicle, February 18, 2012, Sorry isn’t enough, PG&E at p.A11. See, Attachment 1, After Action/Corrective Action Report – Potential Corrective Actions, January 7, 2011. One of the items originally listed (Item 13) required RIMS retraining to the OES staff by December 2011. However, after t he AA/CA report was submitted, it was decided that RIMS procedures would be reviewed and updated resulting in no retraining before the procedures update was completed. As of February 2012 no RIMS retraining has been conducted. 1 conducted interviews, reviewed documents, and made site visits during its investigation of the 13 items to determine if they were implemented and completed on a timely basis. The Grand Jury found that nine of the 13 items were not completed according to their estimated completion date and seven of those were still incomplete as of January 2012. Item 13 was found to be non-applicable because the Response Information Management System (RIMS) is being replaced. The Grand Jury recommends that the Sheriff require the OES to revise its AA/CA Report guidelines to include a formal follow-up procedure to measure progress and completion of improvement plans. The Grand Jury also recommends that OES meet with the local chapter of the American Red Cross to mutually develop a plan for obtaining identity information collected by the Red Cross at the emergency site. Finally, the Grand Jury recommends that the Board of Supervisors and Sheriff’s Office take all necessary steps to establish a fully-equipped and functional County Emergency Office Center (EOC) within 180 days. The current Jury Assembly Room in the Hall of Justice is designated as the primary EOC for large-scale emergency coordination. However, the Grand Jury finds that it is unsuitable as a primary EOC due to its daily use by hundreds of citizens, extremely limited cell phone receptivity, lack of adequate “hardline” telephone connections, and lack of existing electronic hardware. In a county of nearly 750,000 citizens, located in a recognized earthquake zone, large-scale emergencies require a fully-equipped coordination site for emergency services. The Grand Jury highly commends the dedicated performance of all public and private service employees (fire, police, Sheriff’s Deputies, Red Cross, emergency providers, volunteers) on September 10 and for months thereafter. The City of San Bruno also singled out the County Director of Communications, who served as the Public Information Officer (PIO), and the County OES District Coordinator for their exemplary performance assisting San Bruno during the emergency and recovery phases of the incident. We owe all of them our thanks. Background Emergency and Response On September 9, 2010, at about 6:11 p.m., a massive explosion and fire fueled by a ruptured natural gas pipeline spread through the Glenview area in San Bruno. The Glenview fire was among the worst disasters in San Bruno and County history in terms of loss of life, injuries, and property damage. With more than 500 firefighters and police officers responding, and approximately 400 homes evacuated, the State of California declared a State of Emergency for San Mateo County on September 10, 2010. At 6:21 p.m., the San Bruno Fire Department immediately “sized up the situation and established the Glenview Command at the San Bruno Avenue and Glenview Avenue and requested mutual aid.” 3 The San Bruno Police Department established a law command post at 6:46 pm and the City activated its emergency operations center to support the Glenview Incident Command Post 3 After Action/Corrective Action Report, City of San Bruno Preliminary Report, December 27, 2010. 2 (ICP), which was concurrently set up at the incident site.4 At approximately 7:09 p.m., the Sheriff’s Office of Emergency Services (OES) activated its Operational Area EOC near the same location to support San Bruno’s efforts and to allocate County resources assigned to the incident response. OES also activated its EOC in the Sheriff’s Office at 555 County Center, Redwood City at 6:17 p.m. The Sheriff’s OES activated the Telephone Emergency Notification System at 7:47 pm to send a voice message to the homes within three quarters of a mile of the Glenview/Earl intersection instructing voluntary evacuation. From September 9, 2010 through September 12, 2010, the City of San Bruno maintained a shelter for displaced residents, supported by the Red Cross and various County agencies. OES assisted in setting up a Local Assistance Center to enable State, County, City and non-profit agencies to offer services to affected residents. Due to the involvement of the public utility, Pacific Gas and Electric Company, and the loss of life and property, the disaster received nationwide media attention. Public Information Officers (PIOs) and other County employees were assigned to assist with communication activities in order to provide accurate, consistent information. The San Bruno emergency operations remained fully operational to support the Incident Command Post for two weeks and transitioned to a duty officer on September 21, 2010.6 The County deactivated its EOC on September 13, 2010 and assigned a Liaison Officer to San Bruno’s Command Staff to coordinate County resources as needed and to assist the San Bruno City Manager in the preparation of the City of San Bruno EOC Preliminary Report of December 27, 2010. The recovery and rebuilding efforts still continue over a year and a half later. Functions Performed by San Mateo County Sheriff’s Office of Emergency Services during the San Bruno Emergency On September 10, 2010 and thereafter, the OES performed the following functions in response to the San Bruno emergency: Onset Response: • Helped establish an Incident Command System at two sites in San Bruno • Set up EOC at the Sheriff's Office at 555 County Road, Redwood City • Coordinated assignments and equipment deliveries from the County and other agencies • Activated the Telephone Emergency Notification System to instruct residents to evacuate • Activated the SMC Alert System to inform County staff of incident On-Going Response: • Coordinated daily EOC staff meetings and briefings with San Bruno and County and State emergency management agencies 4 The purpose of an EOC is to facilitate a coordinated response by the Director of Emergency Services, the emergency staff, and agency representatives from outside organizations. The ICP is used by the incident Commanders from responsible agencies (fire, law, etc.) to manage the incident. EOC Handbook and Checklist, . After Action/Corrective Action Report, Sheriff’s Area Office of Emergency Services, January 7, 2011. After Action/Corrective Action Report, City of San Bruno Preliminary Report, December 27, 2010. 3 • Coordinated all County agencies active at the scene • Assisted in opening and operating the Local Assistance Center for disaster victims • Worked with San Bruno and the State to make applications for aid from FEMA and the California Disaster Assistance Act7 • Provided OES personnel to support San Bruno through the initial recovery phase that lasted until October 12, 2010.8 San Mateo County Sheriff’s Office of Emergency Services The Sheriff’s Office of Emergency Services (OES) provides a variety of emergency services to the cities of San Mateo County. Within the OES office, there are 11 employees: one Sheriff’s Lieutenant, one Supervising Coordinator, four District Coordinators, two Sheriff’s Sergeants, one Deputy Sheriff, one Fiscal Office Specialist, and one Storekeeper. One of the District Coordinators is a part-time employee. The OES also has several units with specialized skills, mostly staffed by volunteers.9 The SWAT team is not a volunteer unit, but a team composed of sworn members of the Sheriff's office. Many of the unit members are certified in emergency medical response and assist other public safety officers across the County in providing situational care and protection for the citizens of San Mateo County. Additional OES Units with Specialized Skills Special Weapons and Tactics Team (SWAT) Dive/Cliff/Marine Unit *Air Squadron *Bay Area Mountain Rescue Unit (BAMRU) *Communication Unit *Explorer Post 810 (Law Enforcement) *Search and Rescue 830 (Search and Rescue) *Mounted Search and Rescue *San Mateo County Sheriff's Office Search and Technical Team *Involved in the San Bruno emergency efforts. The OES also provides regular coordinated emergency planning and training services to the 20 cities and towns within the County and a wide variety of support and resources to assist cities in dealing with disaster and other emergency situations. The OES maintains an amateur radio repeater for use by the amateur radio community. 7www.calema.CA.gov/.../California-Disaster-assistance-Act-(CDAA).aspx 8 Equipment deliveries included shelter trailers, generators, security/road closure barricades, mobile lighting units, Mobile Communications Units, radios, batteries, portable toilets, mobile hand-washing units, personal protective equipment, water, etc. provided by OES. Personnel assignments coordinated by OES included the following entities: Sheriff’s Office, Co/Cal Fire, Public Works, Health and Human Services, District Attorney’s Office, County Manager’s Office, County Animal Control, Emergency Services Coordinators from cities/special districts throughout the County. (Per email from OES, January 7, 2011). 9 http://smcdirectory.cosanmateo.ca.us/searchUsersForm.html. The OES is funded and governed by the Emergency Services Council through a Joint Powers Agreement (JPA) that includes the 20 cities and towns and the County of San Mateo. The cities and towns of the JPA contribute money to fund the JPA based upon a formula that takes into account the population and average assessed property value of each. The County then matches the funds contributed by the cities and towns. The remainder of the OES budget comes from State and Federal Emergency Management Assistance program funds.10 The budget for OES in 2010-2011 was $1,285,846.11 The Current Location of the Primary Emergency Operations Center in San Mateo County The County’s primary EOC is the Jury Assembly Room located in the basement of the Hall of Justice in Redwood City. This location is used for serious and prolonged emergencies, and overrides everyday use by the Superior Courts. The Jury Assembly Room, while spacious, is clearly sub-optimal for emergency services use. At minimum, usage requires spontaneous relocation of personnel, office and electronic equipment, and operation manuals from other buildings. The subterranean location has severely limited telephone and cell phone coverage, and no dedicated EOC functionality. During the Glenview emergency, the OES utilized the alternate EOC, a smaller, dedicated fully equipped room in a County Office Building at 555 County Center. Red Cross Involvement in the San Bruno Emergency The OES and the American Red Cross work together to assure organization, readiness, and response to an emergency. At Glenview, the Red Cross immediately opened a shelter at the nearby Bayhill Shopping Center and welcomed all who needed help with food and shelter. A representative from the Red Cross registered each person who entered the shelter and took personal information such as name, address, family members to contact and medical issues. Each registered person received a confidentiality statement from Red Cross acknowledging the Red Cross’ agreement to keep the registered person’s information confidential. This statement reads in part: The relationships between the American Red Cross and the people who come to the American Red Cross for disaster relief services are confidential. Safeguarding the trust of our clients is an important part of the organization’s obligation to the people and communities it serves. All American Red Cross employees and volunteers will observe the principle of confidentiality in obtaining, using, protecting and releasing information about American Red Cross clients.12 The confidentiality statement restricted the Red Cross from disclosing the identities of those in Red Cross care and hindered attempts by public safety officers to locate residents and to know that all residences were vacated. 10 http://www.sheriff.com/divisions/operations-division. This is exclusive of outside funding of $215, 833 and the Hazardous Material Program of the budget, per OES email dated January 13, 2012. American Red Cross Shelter Registration Form 5972, Revision February 2007 and Red Cross Commitment to Confidentiality, May 2007 5 Radio Shop Involvement in the San Bruno Emergency The County Radio Shop, which is run by the Information Services Department, is responsible for the direct distribution of its emergency backup radios to agencies or persons in need.13 The radios are intended for short-term use during the disaster phase of the incident. During the recovery phase of the Glenview explosion, the County Health Department requested radios to be used to survey the neighborhood. Since this was outside of the immediate disaster phase, that request was denied. Declaration of Emergency/The After Action/Corrective Action Report The City Manager of San Bruno and the County Manager each declared a local state emergency and the State followed with its declaration of a state of emergency on September 10, 2010. The declaration of a state of emergency required OES to file its AA/CA Report with the Coastal Region Office of the California Emergency Management Agency (CAL EMA) on January 7, 2011, in compliance with the procedures and regulations of the California Standardized Emergency Management System (SEMS) regulation Section 2450(a). Section 2450(a) of the SEMS regulations states: …Any city, city and county, or county declaring a local emergency for which the governor proclaims a state of emergency, and any state agency responding to that emergency shall complete and transmit an after action report to [the State of California] OES within ninety (90) days of the close of the incident as specified in the California Code of Regulations, section 2900(j).14 San Mateo County’s revised “Operational Area” Emergency Operations Plan, which was released on January 28, 2011, included the above SEMS requirement.15 The AA/CA Report is designed to fulfill the following criteria: • Provide a source for documenting response and early recovery activities; • Identify problems and successes during emergency operations; • Analyze the effectiveness of the different components of SEMS; and • Describe and define a plan of corrective action for implementing recommended improvements to existing emergency response efforts.16 As stated above, San Mateo County was required to file an AA/CA Report with the CAL EMA within the 90-day period. The report was due on December 7, 2010. An OES representative requested and received a thirty-day extension from CAL EMA. The AA/AC Report was filed on January 7, 2011, (See, Attachment 1). Trunked Radio Cache Guidelines, August 2007 14 http://www.oes.ca.gov/Operational/OESHome.nsf/PDF/State%20Gov.%20Code/$file/StateBGovtCode. San Mateo County “Operational Area” Emergency Operations Plan; Released January 28, 2011. 16 http://cms.calema.ca.gov/prep_after_corrective_action.aspx 6 Process Used to Create the AA/CA Report To initiate work on the AA/CA Report, the Sheriff’s OES called for a County department debriefing meeting to be held on November 23, 2010.17 The focus and attendees were as follows: Date and Time: Tuesday, November 23, 2010, from 8:30 am to 12:00 noon Focus: Gather input and feedback from a variety of individuals to create the required AA/CA report Attendees: Professionals from several different departments County Commands (County Manager, Public Information, Safety/Human Resources, and County Counsel) Representatives from the Sheriff’s Office, the Coroner’s Office, the EMS branch, the Public Safety Communications branch, the Health/Public/ Environmental/Behavioral branch, the Care and Shelter branch, and Public Works Representatives from the Planning Section, Logistics Section, and Finance The Assessor’s office The District Attorney’s office OES shared [sic] information about the Incident Command Post, the evacuation center, the San Bruno EOC, and the Emergency Operations activations Based on the feedback from outside agencies and the debriefing notes (no formal meeting minutes were published), an OES Coordinator completed the AA/CA Report.18 The report was filed with the State on January 7, 2011 and distributed to the County Manager’s Office, the County Communications Director, Supervisor Adrienne Tissier (representative of the Board of Supervisors on the Emergency Services Council), Public Safety Communications, and members of the media who requested it. The public distribution of the report was determined by expressed interest. San Mateo County Sheriff’s Office of Emergency Services September 9, 2010 Glenview Gas Pipeline Explosion and Fire County Department Debriefing for After Action Report and Improvement Plan, Agenda for Tuesday, November 23, 2010, 8:30 – 12:00 noon. OES emailed a questionnaire to some of the agencies to request feedback. OES unable to provide date the email questionnaire was sent and to whom. See, Attachment 2 – Incident Participant Form. Summary of the AA/CA Report The required AA/CA Report filed by OES (Attachment 1) identified 13 potential corrective actions. Following is a summary of the AA/CA Report with issue, responsible agency, estimated completion date, and current status. # Issue and Corrective Action Plan Agency Estimated Current Involved Completion Status as of Date (Met January /Not Met?] 2012 1 Continue to provide ICS-300 & 400 OES Dec 2011 Incomplete training; schedule EOC staff for ICS EOC Staff Not Met training 2 Continue multi-year training; continue to OES Dec 2011 Incomplete provide training to EOC staff EOC Staff Not Met 3 Integrate Red Cross into EOC structure; OES July 2011 Incomplete discuss info sharing with Red Cross. Red Cross Not Met 4 Develop large status boards for EOC; re- OES July 2011 Incomplete search and purchase status boards for EOC Not Met 5 Question use of current jury room as EOC; OES Dec 2011 Incomplete research alternate location for EOC; Not Met research cell phone connectivity options 6 Review Operational Area EOC awareness; OES July 2011 Complete change procedures to include SMC Alert Not Met 7 Consider joint information center OES July 2011 Complete establishment at site; work with County County Not Met PIO to schedule and conduct training PIO Group 8 Research cell phone coverage at disaster OES Dec 2011 Incomplete site; research solutions to cell phone Radio Not Met connectivity issues in major event Shop 9 Continue scheduled training for more OES Dec 2011 Complete Planning Section Staff Met 10 Review Ham Operator activation; review OES Dec 2011 Complete procedure for activating/assigning Met Volunteer HAM to ICP or EOC; update procedures as needed. Clarify radio cache distribution; clarify OES July 2011 Incomplete radio distribution policy and modify if Radio Not Met necessary. Shop 12 Activate finance section earlier; change OES July 2011 Complete policy to call all EOC sections to EOC Met upon an EOC activation. Provide RIMS training to the EOC staff. OES Dec 2011 N/A (Note: RIMS is being replaced) EOC Staff 8 Investigation The Grand Jury gathered and reviewed data from numerous sources including: • Nineteen interviews with 14 members of the San Mateo County departments listed in the AA/CA Report (County Manager’s Office, Information Services, Sheriff’s Office, OES, Health & Human Services), and the American Red Cross, the City of San Bruno, and the San Bruno Police and Fire Departments. Interviewees included administrators, managers, supervisors, and staff of these entities/organizations. • The required AA/CA Report filed by the County OES (Attachment 1) that identified 13 corrective actions. Item 13 was found to be non-applicable. • The City of San Bruno’s EOC Preliminary AA/CA Report, filed by the City of San Bruno Preliminary Report, December 27, 2010. • Tours of the gas pipeline explosion area in the Glenview neighborhood in San Bruno, the Emergency Control Center in the OES office, and the Jury Assembly Room at the Courthouse in Redwood City. • The Emergency Operations Center Handbook and Checklist (no published date) • The SMC Operational Area Emergency Operations Plan, EOC Guidebook (March 2007 and January 28, 2011 draft revision) • The Sheriff’s Office OES & Emergency Services Bureau Presentation, October 19, 2011 • Sheriff’s Area OES Customer Service Questionnaire (2011) • San Mateo County’s Multiyear Training and Exercise Plans 2010-2011 • ICS-300 Student Manual, Unit 3, Unified Command (September 2005) • Course descriptions and rosters for: Incident Command System (ICS) training (quarterly 2011), Joint Information Center Training (April 2011), Joint Commercial Aircraft Crash Exercise and Checklist (October 2011) • Incident Command System training course student evaluations (August – November 2011) • Agenda for After Action Report and Improvement Plan debriefing session November 23, 2010 • Written responses to follow-up interview questions from OES, Information Services and the County Manager’s Office (October 2011- January 2012) 9 • San Mateo County Health System San Bruno Fire 2010 AAR/Improvement Plan, November 2010 • American Red Cross Commitment to Confidentiality document (exemplar - May 2007) • American Red Cross Shelter Registration Form (exemplar – February 2007) • Trunked Radio Cache Guidelines (August 2007) • San Mateo County Emergency Operations Plan EOC Activation Appendix (December 2011) 10 Findings The Grand Jury finds that: 1. The AA/CA Report was due on December 7, 2010. OES requested and received a thirty-day extension from the Coastal Region Office of CAL EMA; a final AA/AC report was filed on January 7, 2011.