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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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Report No. 2003-P-00012
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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Report No. 2003-P-00012
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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