686 Explosion on Broadway PHSA Review of Lessons Learned Overview - - PowerPoint PPT Presentation

686 Explosion on Broadway

PHSA Review of Lessons Learned

2

Overview of PHSA

BC Cancer Agency Mental Health & Addiction Services - Riverview Hospital Psychiatric Institute BC Centre for Disease Control BC Women’s Hospital and Health Center Cardiac Services of BC BC Transplant BC Provincial Renal Agency PHSA Laboratories BC Children’s Hospital and Sunny Hill Health Centre for Children The Provincial Langue Services Provincial Blood Coordination Office Provincial Health Services Authority

4

Overview of 686

9th Floor 8th Floor 7th Floor 6th Floor 5th Floor Ground Floor 3 Levels Parking

PHSA Laboratories Cervical Cancer Screening Program Screening Mammography of BC BCCA Multi Media Services BC Cancer Foundation 70 Parking Stalls Retail Unites and Office Tenants Office Tenants

5

Gaining Access

First Stage for IMIT and very limited Staff

• Fire
• Police crime scene
• Landlord – “release of liability and indemnity agreement”
• Ministry of Finance – HPRMB approval
• PHSA – Chief Financial Officer approval
• OH&S

Second Stage Retrieval of Critical Equipment & Files

• OH&S
• WorkSafe
• Unions

6

Complexity of Information

• Fire / Police / City of Van / Landlord
• PHSA Lab’s / Cancer Agency
• Confirming or Dispelling Rumors'
• Communication to Senior Leaders
• Communication to Effected Staff
• Communication to Media
• Communication to Clients
• Communications within the response team
• Communication to other Staff

7

Time-Line

2/13/2008 3/31/2008 3/1/2008 2/13/2008 Explostion 2/14/2008 G ained Access to Building 2/19/2008 Critical Equipm ent Retrieval 2/28/2008 Staff Inform ation Session 3/17/2008 M oved Back In

2 /1 3 /2 0 0 8 4 /2 9 /2 0 0 9 3 /0 8 4 /0 8 5 /0 8 6 /0 8 7 /0 8 8 /0 8 9 /0 8 1 0 /0 81 1 /0 81 2 /0 8 1 /0 9 2 /0 9 3 /0 9 4 /0 9 1 3 F e b ru a ry, 2 0 0 8 E xp lo stio n 1 8 M a rch , 2 0 0 8 P H S A R e tu rn s 1 3 Ju ly, 2 0 0 8 5 B u sin e sse s R e tu rn 2 9 M a rch , 2 0 0 9 2 B u sin e ss S till O u t

8

Administration Lessons Learned

• Don’t assume that because there are no patients, the planning

process and the Plan can wait

• Don’t assume that what you perceive is “small stuff” will be
• Create a central dB regarding facilities, services, staff numbers
• Know your Occupational Health and Safety Team
• Communications, communications, communications
• Ensure ‘loop closing’ on requests and expectations

Cervical Cancer Screening Program / School of Cytotechnology

686 Broadway Incident February 13, 2008

10

9th Floor 686 W Broadway – who are we?

• 9th floor is leased space of PHSA Laboratories / BCCA site
• 2 Laboratory Departments are located in this space
• Cervical Cancer Screening Laboratory – analytical

(microscopic) area

• School of Cytotechnology

11

Cervical Cancer Screening Laboratory

• Performs testing associated with the BC Provincial Cervical

Cancer Screening Program

• Since this is a provincial program, all the pap smears in BC

are screened at this location

• Approximately 600,000 smears are screened annually ≈

2400 per day

• 54 staff working in the department – cytotechnologists (52),

clerical staff (2)

12

Cervical Cancer Screening Laboratory

• Pap smears from all over BC arrive by courier and post at

Central Processing Laboratory (CPR) 655 W 12th Ave

• CPR staff unpack, data enter patient demographics into

Laboratory Information System (LIS), barcode the slides, stain the smears, coverslip slides, load slide carriers

• Slides are delivered by courier to 686 W Broadway for

microscopic examination

13

Pap Smear

14

School of Cytotechnology

• Only accredited school for cytotechnology in British Columbia

(1 of 7 in Canada)

• Operates as part of PHSA Laboratories in conjunction with

BCIT and teaching hospitals in BC

• 3 instructors in school and 7 students
• Plus one fish tank!

15

CCSL and School

• Both areas operate Monday to Friday excluding statutory

holidays

• Some flex hours – staff may start as early as 0600 hours and

premises are typically vacated by 1900 hours

• No staff were on site at the time of the explosion
• Approximately 5000 square feet of space was vacated

16

Day 1 – February 13

• BCCA Administrator on-call notified manager / chief tech that

explosion had occurred

• All staff were contacted or attempt made
• No operations possible – alternate arrangements examined
• No staff wages lost
• Contact would be made daily with staff to give status

17

Day 1 – Options

• Discontinue operations until re-entry to building. Quickly

became apparent that this would not be timely

• Refer out slides to another province or US – no readily

available capacity for volume plus LIS barriers

• Re-locate operations
• Space for 60+ staff and students – environmentally and

ergonomically acceptable

• Computers, microscopes, barcode scanners, chairs,

storage

• Accessible for deliveries, staff parking, transportation etc

18

Re-locate operations

• We did not have formal emergency management or business

continuity plans

• We did have thorough knowledge of our businesses, needs and

support systems

• We did discover that we had networks within PHSA that were

collaborative and enabling

• We had some dedicated employees that would go above and

beyond

19

Re-locate operations

• No space was immediately available that met all our needs –

equipment, connectivity, space

• Laboratory space identified at Cancer Research Center – 675 W

10th Ave; approximately one third space

• Small working space identified 4th floor BCCA

20

CRC Re-location / CCSL

• Server was not located at 686 W Broadway and connectivity

could be established

• No microscopes available – contacted vendors, community

laboratories, conference providers – no adequate supply readily available

• IMIT able to provide correct version computers but not barcode

scanners

21

PHSA Laboratories Staff - not our usual labcoats!

22

These are not figure flattering outfits!

23

9th Floor Retrieval

• 8 staff were fit tested and allowed to enter building
• Entry through parking level
• Carried out 30 microscopes, scanners, approximately 10,000

unscreened slides

• Removed teaching items and fish tank from School
• All items were “decontaminated” upon removal

24

Temporary CCSL Location Setup

25

CCSL Relocation

• Incident occurred Feb 13, CCSL back in operation Feb 18
• Temporary space could accommodate ½ staff
• Moved to 2 shifts – day, evening shifts rotated
• Issues – parking, transit, personal accommodations eg.

Daycare

• Uncertainty how long this would last

26

School of Cytotechnology

• Small space identified at 600 W 10th (BCCA)
• Students were able to be moved through Diagnostic Cytology

Lab, temporary space and BCIT

• Instructors were very flexible – because clinical laboratory

testing is not done, there was not the same impact on patient care

27

Financial Impact

• Very little had to be purchased
• Much of the setup by IMIT, facilities and administration was

done at no additional cost

• Cost in lost time, additional shift premiums, overtime and union

contract requirements ≈ $75,000

– 3 days paid / no productivity – evening shift premium – 3 days overtime (weekends) – 1 day notification of change = 1.5X

28

Lessons Learned

• Recognize, acknowledge and appreciate all those

that help

• Prioritize
• Keep everyone up-to-date
• Don’t sweat the small stuff
• Be flexible
• Develop emergency management and business

continuity plans

The explosion at 686 West Broadway

Response

30

• 0234 explosion inside 686 West Broadway
• 0237 camera on the rear of BCCRC records individual running

down the laneway

• 0245 individual is picked up by cab at Ash and Cambie
• 0246 first responders police & fire on scene at 686
• 0445 BCCA Administrator on-call alerted by security
• 0549 BCCA. Emergency Manager alerted by COO
• 0623 on scene incident command post established
• 0717 initial meeting of senior staff BCCA
• 1030 first formal Emergency Command Center meeting held 4th

floor Boardroom Vancouver Cancer Centre.

Response-timelines

31

Standing up the incident command post

• Vehicle with green lights and response kit on scene and in

place in the lane way to the rear of the building

• Negotiations allowed utilization of the underground parking for

setup & security

• By midmorning tables and set up ‘system’ obtained
• Post included safety personnel, emergency management and

facilities staff as well as on scene consultants

32

Site safety

• Shockwave created significant quantities of dust with high

probability of asbestos content

• Staff entering the building fit tested for N 95 respirator and

provided with Tyvak suits, hard hats, eye protection, vests

• Stairwells lit with glow sticks & headlights
• All staff given safety briefing prior to entry
• All staff required to sign in and out from building
• Congestion in the lane way required flag person

33

34

Site communications

• Equipment: used FRS radios
• Messaging: BCCA Communications group provided media

communications

• Building contained for BCCA programs and staff started to arrive prior

to ICP.

• Senior staff asked to stay and attend meetings around service

disruption

• the staff told building closed that day.
• Ongoing staff communications provided the greatest challenge

without departmental emergency plans and contact numbers

35

Site liaison

• Initial liaison established with VPD and crime scene status of

building established

• Contact maintained with building guard service
• Contact established and maintained with building owners

representative

• On scene incident commander provided liaison to BCCA

Operations Committee

• An on scene log was maintained

36

Response operations

• The need for building entry and recovery of assets established

at first meeting

• Consultants obtained for fit testing, air quality assessment and

asset cleaning

• Chain of custody important for medical records
• Entry requirements, booking times, approved staff numbers

and assets to be recovered established

• Followed the protocols of determining an Operational Period,

Response Objectives and an Incident Action Plan

37

38

Response planning

• Event occurred on Wednesday, February 13 08
• First entry occurred on Friday 15th
• Over the weekend a detailed re entry plan developed
• Second entry occurred on Tuesday 19th
• Recorder provided at each of the operations meetings
• Microsoft Project used to identify and plan activities
• Return and reoccupation plan developed

39

40

Response logistics

• Cytology utilizes specialized microscopes, specialized chairs

and “bench space”

• Transportation of cytology slides presented a challenge due to

number and limited building access

• Facilities challenged to find alternate space for four programs
• IMIT challenged regarding server recovery for SMP and for

telecommunications reestablishment

• Documentation required for all assets

41

42

43

Finance and Administration

• Waiver had to be obtained from the Ministry of Finance in favor
• f building owner in order to obtain entry –time delay
• Small equipment, lights, refreshments etc. initially purchased
• n individual credit cards later on corporate credit card
• Employees paid for parking which was no longer available and

the issue remained unresolved

• Finance did not have any charge number to consolidate costs
• f the event

44

LESSONS LEARNED

• Establish the Liaison role as soon as

possible

• Be ‘credible’ - Vests Help!!
• Determine ‘ Damage’ ASAP
• Ensure you have organizational agreement
• n the INCIDENT ACTION PLAN
• Involve Finance from the beginning
• While in Response start your Return and

Reoccupation or Relocation Plan

Will Davies

Facilities & Planning

Operational Nightmare

Response, Recovery & Ruminate

Ruminate (Contemplate & Plan) before and after an event

47

Operational Response

The 6 Stages of a Project The 6 Stages of an Project Unplanned Emergency

• Enthusiasm
• Depression
• Panic
• Search for the Guilty
• Punishment of the Innocent
• Rewards for the Non-Participants

Speaks to Diversity of Emotions and Concerns

48

Operational Response

Disadvantaged … no earthquakes, no bombs dropping, no bullets to dodge …this can be a deterrent to action No matter how prepared…there is always a surprise factor Success in managing this event…came down to the competency of the people and the relationships developed. Where there are no injuries - effectively, Business Continuity starts at the moment an event occurs

49

Operational Response Stages

50

Challenges and Realizations

• Mobilization
• Managing expectations
• Managing behaviour
• Others actions beyond your control – how do you adjust to

compensate?

• Ensuring people are in place – beforehand (who will you call on?)
• Space management – have a plan, but, can be “call of the moment”
• Location Options - Should we stay where we are or find a new

place?

• Establishing clear mandate
• Corporate decisions - where should our programs be? What things

need to be in our control?

51

Peripheral advantageous elements (a.k.a. side benefits)

• Hopefully…
• Increases the acknowledgement of mutual dependency
• Subsequently, the value of all elements and pieces of an
• rganization… can’t silo…challenge in many organizations
• Understand our organization and know why people are there.
• Humility – no person is an island
• The value of preparation needs to be recognized and supported by
• rganizations
• Practical and realistic (ego-free) planning is the key to success and

longevity

• Teaches people value of what they have

52

Lessons Learned

• Believe in the need of emergency preparation and commit to the

execution - Companies & Corporations, large or small

• Emergency Management/Business Continuity like insurance – it

costs now, but it will save you in the end

• Have Base Plan - Know what you have - Build with what you have
• Don’t delay for speculative future growth, changes or possibilities
• Clearly determine in advance – Key Players
• Education, planning and training is essential
• A Plan is good for any Emergency event – site water leak, power
• utage
• One final key lesson…..

53

Lessons Learned

Don’t wait ‘til Spring – Do it now!

54

Final disposition of the incident

• A person of interest was arrested
• That person was charged
• The Crown has stayed the charges
• The Crown expects to develop more forensic evidence
• The Crown Counsel anticipates charges will be reinstituted in

this case

• One life was lost but not at the scene of the explosion