APPROVED: National Park Service U.S. Department of the Interior Northeast Region
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Operational Risk Management Assessment Special Use Permits Annual Yorktown Fourth of July Celebration Colonial National Historical Park
February 17, 2012
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I. Purpose & History Introduction & Purpose In December, 2011, the Risk Management department of the National Park Service-Northeast Regional Office undertook a review of Fourth of July special events at Colonial National Historical Park (COLO), Yorktown, Virginia. This detailed systemic review is referred to as an Operational Risk Management Assessment (OLA). The department evaluated the risks to employees and visitors as well as the potential gains (visitor access, agency cost, and resource protection) of the annual special event. The overall objective of operations at Colonial National Historical Park is to avoid negative impacts to visitors, employees and natural resources. Figure 1 illustrates the location of Colonial National Historical Park. Figure 2 illustrates the Operations Map for the Fourth of July special event. The process was lead by the Regional Safety & Occupational Health Program Manager. The primary audience for this report is the Colonial National Historical Park management team. The secondary audience for this report is the communities of the Historic Triangle of Virginia: York County, City of Williamsburg, and James City County, Virginia.
Figure 1: Location of Colonial National Historical Park.
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Figure 2: Yorktown Operations Map for 4th of July Events
Historical Considerations of Visitor and Employee Safety Colonial National Historical Park began issuing Special Use Permits for the Fourth of July activities, including the display of Fireworks, in 1982. The permits were initially issued to local committees which organized the events, but in more recent years have been issued to the County of York. A separate Special Use Permit has usually also been issued to a running event on the battlefield tour roads in the morning hours. It is unknown how many 4th of July events were cancelled under previous Superintendents, however, in the last eight (8) years; a decision to revoke the Special Use Permit has been made by the COLO Superintendent in 2004, 2009 and 2011. All cancellations were weather-related. Furthermore, COLO management felt the decision to cancel should have been made in other years due to other environmental conditions such as dry conditions and heightened wildland fire hazards due to drought. In 2004, the cancellation decision was made early in the afternoon because of the amount of rainfall and the condition of the battlefield, which was too wet to use for vehicle parking without significant resource damage. Subsequent lightning experienced later in the afternoon was an additional consideration. In 2009, the Park Superintendent cancelled the Special Use Permit at approximately 8:00 p.m., and in 2011, the Superintendent made that decision at 6:45 p.m. With the availability of weather forecasts from
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the National Weather Service station in Wakefield, Virginia, the Superintendent felt the information about impending severe weather should have prompted the permittee to have made a cancellation decision early in the afternoon. In both 2009 and 2011, the Park had approximately 10,000 persons in attendance and no ability to move them to their vehicles or to a safe area within 30 to 45 minutes. In 2011 there were three (3) cloud to ground lightning strikes within the Park, all within several hundred yards of visitors who were totally exposed to the risk and had no available shelter. Each time the decision has been made by the NPS Superintendent to cancel the Special Use Permit only after the permittee has not been willing to take that action. The risk has been completely taken by the Superintendent upon approving the Special Use Permit for York County. National Park Service Management Policies 2006, Section 8.6 Special Park Uses, Subsection 8.6.2.3 Fireworks Displays states: Fireworks displays will be considered unless they pose an unacceptable risk of wildland or structural fire or will cause unacceptable impacts on park resources or values or jeopardize public safety. In all instances, the decision to approve or deny a request will be made by the superintendent following consultation with the regional safety officer. The fireworks associated with this event are provided by a private contractor hired by York County. They are stored and discharged from National Park Service property known as the “Beach Picnic Area.” Their use is required by terms of the Special Use Permit to conform to the standards of the National Fire Protection Association Standard 1123, Code for Fireworks Displays, 2010 edition. Direct supervision of the fireworks operation is provided by York County Fire & Life Safety, but the park lacks the technical expertise to oversee this area. It is also noted that the fallout zone for the fireworks includes the National Park Service Visitor Center, a historic frame dwelling owned by the NPS, and the iconic Yorktown Victory Monument. It was noted that other units of the National Park System have evaluated risks associated with fireworks displays on the Fourth of July. Fireworks have been cancelled at Cape Hatteras National Seashore, North Carolina because of the pyrotechnic risks, and Mount Rushmore National Memorial, South Dakota, because of wildland fire danger.
In addition, Code of Federal Regulations Title 36—Parks, Forests, and Public Property, Chapter I— National Park Service, Department of the Interior, Part 2 Resource Protection, Public Use and Recreation, Section 2.50 Special events states: (a) Sports events, pageants, regattas, public spectator attractions, entertainments, ceremonies, and similar events are allowed: Provided, however, there is a meaningful association between the park area and the events, and the observance contributes to visitor understanding of the significance of the park area, and a permit therefore has been issued by the superintendent. A permit shall be denied if such activities would: (5) Present a clear and present danger to the public health and safety Issuance of a Special Park Use for a special event in a unit of the National Park Service is a discretionary authority of the park superintendent.
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II. Operational Risk Management Process The National Park Service is making a priority to integrate Operational Risk Management (ORM) into NPS safety culture. The Northeast Region is implementing ORM in all aspects of their operations branch; doing so is influencing the way the agency functions from the inside out. A key feature is that Operational Risk Management does not tell you what to do, it gives you an accurate assessment of ALL risks and asks the question: “What is acceptable to you?” Four Core Principles Four core principles of ORM exist that facilitate the critical thinking necessary to objectively complete this assessment: 1) Accept no unnecessary risk 2) Accept risk when benefits outweigh the cost 3) Anticipate and manage risk by planning 4) Make risk decisions at the right level 7 Critical NPS Operational Risk Management Principles 1. Effective Leadership 2. Error & Accident Causation 3. Mission Analysis 4. Stress & Performance 5. Situational Awareness 6. Decision Making 7. Communications & Assertiveness Green-Amber-Red—The “GAR” Model GAR is a dynamic, fluid tool, not a static exercise. Users can use it to continually adjust operations to minimize risk and maximize gains. GAR stands for Green, Amber, Red as depicted in the simple rating scale in Figure 3. The GAR is a model and tool that is ideally used to evaluate an individual rotation of a field operation and is also used to assess operations programmatically (the typical conditions of a recurring operation). Numbers correlate with the colors to serve as a guideline measurement, and should not be considered a steadfast definition of risk or hazard. ORM recognizes that different organizations and workgroups within organizations have different levels of acceptable risk (i.e. the training division of an organization typically has a lower tolerance for risk than the operational division, the military typically has a higher tolerance of risk than a civilian organization, and/or the military has a higher tolerance of risk when at war than during peaceful periods). It is up to an organization’s leadership to define what levels of risk are appropriate. Risk Calculation Hazard mitigation options are rated on a scale of 1 to 10, with 10 being most risky. The eight operational components are found in Figure 3. Upon rating each component, they are totaled, by adding, and the final number is then cross-referenced with the appropriate color range (Green-Amber-Red).
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Figure 3. GAR Scale. Numbers on the scale are derived from the Coast Guard scale as modified for NPS application. The numbers and colors are intended to serve as a qualitative and quantitative indication of risk. The chart below applies this scale to the identified options for fireworks risk at Colonial National Historical Park. Operational Risk Management Analysis (ORMA) Rate 1-10 Any category rated > 5 should receive specific mitigation
1. Supervision
Presence of, qualified, accessibility & effectiveness. Clear chain of command?
2. Planning
Information available & clear, adequate time to plan, SOP’s, pre-plans, brief’s, team input solicited?
3. Contingency Resources
MOU’s and planning in place. Shared communications plan?
4. Communication
Radio communications, environment that values input, de-confliction?
5. Team Selection
Level of training and experience. Cohesiveness & atmosphere that values input?
6. Team Fitness
Physical & Mental state of the team? Consider rest, fatigue, morale, outside distractions?
7. Environment
Threats, time of day, extreme temperatures, elevation, difficulty of terrain, remoteness?
8. Incident Complexity
Exposure time, severity & probability of mishap, potential for taxing staffing levels?
Green (1-35)
Amber (36-60)
Red (61-80)
Working Definitions of GAR Elements Supervision Supervisory control should consider both how qualified the supervisor is and also whether supervision is actually taking place. Even if a person is qualified to perform a task, supervision, even as simple as verifying the correctness of a task, further minimizes risk. The higher the risk, the more the supervisor needs to be focused on observing and monitoring. A supervisor actively involved in a task can be distracted easily and probably is not an effective safety observer in moderate to high-risk conditions. Planning Planning and preparation should consider how much information one has, how clear it is, and how much time one has to plan the incident or evaluate the situation. Planning includes the use of pre-defined plans and on-site incident plans. For example, ensuring the availability of correct equipment for the operation/task and that it is in good working order. Contingency Resources Contingency resources should include those pre-defined resources that will be called upon in an overwhelming incident. A few items to consider include: Who is to be called, are they available and are they capable of responding to the incident? Communication Communications need to ensure clear and accurate sending and acknowledging of information, instructions, and commands; and provision of useful feedback. Items to consider are not only interpersonal communications but also the physical communication equipment.
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Team Selection Team selection should consider the qualifications and experience level of the individuals used for the specific incident or operation. Individuals may need to be replaced during the incident or in the operation. The same concerns apply to the contingency resources and relief teams. Teams should have an adequate number of members from which to choose for any single mission and ensure they are trained. Team Fitness Team fitness should consider the physical and mental state of the team. This is a function of the amount and quality of rest a team member has had. Quality of rest should consider sleeping conditions, potential sleep length, and any interruptions. Other factors to consider are physical preparedness and personal life factors that may impede the outcome of the operation. Environment Environment should consider factors affecting personnel performance and factors affecting the performance of equipment, vehicles, vessels, or aircraft. This includes, but is not limited to, time of day, wind exposure, temperature, humidity, precipitation, elevation, isolation, vertical exposure, proximity to aerial/navigational hazards and other exposures (e.g. oxygen deficiency, toxic chemicals, and/or injury from falls and sharp objects). Incident Complexity Incident complexity should consider both the required time and the situation. The longer exposed to a hazard, the greater the risks. Factors considered include how long the environmental conditions will remain stable and the complexity of the work.
The Severity, Probability and Exposure Model In the Severity-Probability-Exposure (SPE) risk model, a different measurement of risk is obtained from the formula: Risk = Severity x Probability x Exposure. This is a model used to take a closer look at specific operations and is helpful to consider when planning ongoing operations. In this ORM, the assessment relied primarily upon the GAR model, but used the SPE model to illustrate the risks from three options. The definitions of the SPE components are: Severity: the potential loss or consequences of a mishap (Risk Control such as protective devices, engineering controls, and personal protective equipment are used to control Severity.) Probability: the likelihood that given a certain exposure, the projected consequences will occur. (Risk Control--training, awareness, attitude change, etc.) Exposure: the amount of time, number of cycles, number of people involved, and/or amount of equipment involved (Risk Control--reducing the number of people involved, the number of events, cycles, evolutions, etc.). To rate the Risk of an option under the SPE model, the severity is ranked on a scale of 1 to 5 (5 being worst), probability on the same scale (5 being highest probability), and exposure on a scale of 1 to 4 (4 being worst) and then multiply the ratings to achieve an overall score. Figure 4, illustrates how those multiples would be considered qualitatively. To use the SPE model, the risk levels for each hazard identified are calculated. Those hazards can then be rank ordered from the highest to the lowest risk.
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Figure 4: SPE Worksheet
SEVERITY PROBABILITY EXPOSURE (SPE) SEVERITY
PROBABILITY
EXPOSURE
1. None or slight 2. Minimal 3. Significant 4. Major
1. Impossible or remote in any conditions
1. None or below average
2. Unlikely under normal conditions 3. About 50 / 50 4. Greater than 50%
2. Average 3. Above average 4. Great
5. Catastrophic
5. Very likely to happen
VALUES
RISK LEVEL
ACTION
80-100
Very High
Discontinue, Stop
60-79
High
Immediate Correction
40-59
Substantial
Correction Required
20-39
Possible
Attention Needed
1-19
Slight
Possibly Acceptable
Universal Risk Considerations The concept of “Universal Risk Considerations” involves broader factors which must be considered when implementing an operation. For example, managers must consider impacts upon other facets of park operations when implementing a specific project. Some Universal Risk Considerations include injury, occupational illness or death; equipment damage and fiscal resources; adverse or positive public impacts; reduced morale; adverse administrative and/or disciplinary actions.
Operational Risk Assessment The basis of this review was to evaluate operational risk in Colonial National Historical Park during the annual 4th of July fireworks displays. The eight (8) ORM factors were assessed and ranked. 1. Supervision/Visitor Management-This is an externally driven event, conducted by York County through a Special Use Permit. The Park provides resources such as law enforcement and maintenance for both pre-event planning and coordination during the event. The Coast Guard, additional NPS Rangers and Sheriff’s officers are brought in for the event. Parking is organized, but as the Park does not have enough overflow parking, parts of the battlefield are used. Some 2,300 vehicles may be parked on the one battlefield and an estimated 12,000 spectators attend the event each year. 2. Planning-The Park redirects areas of the Colonial Parkway to allow for the flow of traffic into the Park, via a temporary one-way road, and exiting the Park, on another one way tour road for this event. Parking is organized in the overflow areas and the battlefield. There are some shuttles bringing spectators from town into the Park and many locals walk to the event. Those walking usually use the Colonial Parkway which has no crosswalks or lighting. Many visitors attend the event for extended periods of time (up to 12 hours) and shelter is generally not available. In the event of an emergency such as extreme weather or fire, more than 10,000 visitors would exit the Park simultaneously either on foot, or by vehicles. Thousands of vehicles would attempt to leave the Park on the single, designated, narrow Park road. Ambulances and tow trucks are on scene and available, but there is limited area to maneuver due to natural terrain of the Park.
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3. Contingency Resources-Additional NPS law enforcement staff is brought in for the event. York County Sheriff’s Office, Fire and Life Safety, Parks and Recreation, and General Services personnel conduct the event.. Contingency plans are in place, including plans for canceling the event due to extreme weather conditions or other emergency. However, County and NPS officials are not always in agreement as to whether to cancel an event, although ultimately, the Park Superintendent has the authority by virtue of the Special Use Permit. 4. Communication-York County public safety departments participate with the NPS staff and during the event a command center is established. However, the incident command system does not follow National Incident Management System (NIMS) protocols and does not function as a unified Incident Command Post. Redundancy of communication systems are in place, utilizing the park’s VHF radio systems and an 800 MHz trunked system operated by York County. However, communication to visitors is seriously lacking in the event of an emergency and cancellation of the event. Furthermore, when the decision needs to be made as to whether to continue to hold or cancel the event in the face of severe weather, York County, as permittee under the Special Use Permit, has historically sought to delay or avoid the decision. 5. Team Selection-A number of full-time NPS staff are on-site and are well trained and experienced. Seasonal employees are also brought in to assist and have less experience for such an event. Additionally, Rangers are brought is from surrounding parks who may be less familiar with the COLO 4th of July fireworks event. As this is a York County event, the NPS has less control over the criterion for teams brought in at the county or contractor level. 6. Team Fitness-Rangers worked extended shifts for multiple days (15 hour days). Rangers from surrounding Parks are less familiar with the park and seasonals are not as experienced. The maintenance staff also had very long hours for a number of days in preparation for, and during the event. It was also noted that York County personnel work extended tours of duty in support of the event. Conditions are typical of Virginia summers which include high heat and humidity. 7. Environment-At least three times in the last 8 years, weather has been severe enough that the event was canceled by the Superintendent revoking the Special Use Permit. Lightning strikes occurred only yards from where spectators were watching the parade on Main Street. One year was extremely dry and the fire danger very high. Temperatures and humidity are both high during July in southern Virginia and it is not uncommon to see both in the 90s (degrees and percent). 8. Incident Complexity-This event involves weeks of prior planning, traffic control, closing of roads, hundreds of vehicles parking within the Park boundaries (2,300 on the Battlefield) and approximately 12,000 men, women and children in attendance. Visitors are also on foot walking in and around moving vehicles and on the Colonial Parkway after the event which has no lighting or crosswalks. Entry into and egress from the Park is limited to one road in each direction. Coordination is required with COLO staff, surrounding park staff that are in assistance, local law enforcement, EMS, and private business services such as towing. The assessment of the eight ORM factors for this event totaled 58 which are in the high Amber zone (Figure 5). Mitigation or re-consideration of the risks should be reviewed. In addition, all of the categories, ranked five (5) or higher, which indicates each category should be re-evaluated and methods to reduce the risks should be considered and implemented.
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Figure 5. GAR Assessment
It should be noted that this assessment did not take into account the cultural and natural resource damage that is done each year to the Park following this event due to parking on the battlefield and thousands of people on the Park grounds at once. It also does not allow for the amount of money spent each year by the Park to repair the damages. Environmental review of the program conducted several years ago was a factor in “shortening” the day and reducing cumulative impacts to park resources. However, issues regarding preservation of the park’s resources and providing visitor services remains a concern to park management. The assessment for the morning running events which are managed by a separate Special Use Permit did not indicate any safety concerns with those activities.
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