GAO-05-716, U.S. Postal Service: Guidance on Suspicious Mail Needs Further Refinement

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Report to the Ranking Minority Member, Committee on Homeland Security
and Governmental Affairs, U.S. Senate:

July 2005:

U.S. Postal Service:

Guidance on Suspicious Mail Needs Further Refinement:

GAO-05-716:

GAO Highlights:

Highlights of GAO-05-716, a report to the Ranking Minority Member,
Committee on Homeland Security and Governmental Affairs, U.S. Senate.

Why GAO Did This Study:

In October 2003, an envelope marked “Caution: Ricin Poison” was
discovered at an airmail facility in Greenville, South Carolina. Ricin
is a poison that, in certain forms, can cause death. The U.S. Postal
Service has emphasized to its employees to be on the alert for
“suspicious mail” that may pose a threat and has developed guidance for
them on how to identify and respond to such mail, in order to protect
them from harm. Postal inspectors and emergency responders help in the
responses to suspicious mail by performing an initial assessment of the
threat it poses.

This report describes (1) actions taken by various agencies, in
responding to the incident, to protect the health of postal employees
and the public; (2) Postal Service guidance related to suspicious mail
in place in October 2003 and the extent to which it was followed during
the incident; and (3) subsequent changes made in this guidance and the
extent to which current guidance addresses issues raised by the
incident.

What GAO Found:

Postal Service personnel identified the envelope in question as suspect
and took some initial actions in response, such as moving it to a room
away from employees. However, personnel did not speak with postal
inspectors or emergency responders about the envelope until 12 hours
after its discovery. Subsequently, a multiagency response took place.
Key efforts included testing of the envelope and its contents,
monitoring the health of employees and the public, sampling the
facility for contamination, and communicating information to employees
and unions.

At the time of the 2003 incident, the Postal Service had in place
several guidelines on identifying and responding to suspicious
mail—which emphasized steps to take, such as not moving an identified
envelope or package, to protect employees. However, during the
response, postal personnel did not fully follow this guidance, and a
lack of consistency and clarity in the guidance may have been a
contributing factor. For example, the instructions in the suspicious
mail guidelines were not consistent, and it was not clear whether one
guideline applied to nonanthrax scenarios. In addition, the Postal
Service had some guidance on communicating with employees and unions
regarding suspicious mail incidents, and its efforts to inform them
about this incident generally followed this guidance. However, a lack
of specific instructions on who should provide and receive information
and when may have contributed to some communications issues that arose.

Since the incident, the Postal Service has made a number of changes in
its guidance that have improved its consistency and clarity. For
example, it issued new, simpler uniform guidelines on identifying and
responding to suspicious mail and has emphasized these guidelines in
monthly talks to employees. However, current guidance does not fully
address issues raised by the incident because some key elements are
lacking. For example, training for managers does not present all the
guidance they may need to decide whether a piece of mail is indeed
suspicious and response actions are warranted. Also, the Postal Service
has not provided managers with explicit guidance on communicating with
employees and unions regarding suspicious mail incidents. Such guidance
is important to ensure that employees and unions are kept informed,
particularly when a mail piece is suspected of posing a biological or
chemical threat and is sent for testing. Postal Service personnel
identified the envelope in question as suspect and took some initial
actions in response, such as moving it to a room away from employees.
However, personnel did not speak with postal inspectors or emergency
responders about the envelope until 12 hours after its discovery.
Subsequently, a multiagency response took place. Key efforts included
testing of the envelope and its contents, monitoring the health of
employees and the public, sampling the facility for contamination, and
communicating information to employees and unions.

What GAO Recommends:

GAO is making recommendations to further improve the Postal Service’s
guidance related to suspicious mail, to help ensure that postal
personnel are prepared to respond to future incidents. The Postal
Service indicated that it generally agreed with these recommendations
and will take action on them.

[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-716.]

To view the full product, including the scope and methodology, click on
the link above. For more information, contact Katherine Siggerud at
(202) 512-2834 or siggerudk@gao.gov.

[End of Section]

Contents:

Letter:

Results in Brief:

Background:

USPS, the State Health Department, and CDC Took Actions to Protect the
Health of Employees and the Public:

USPS Guidance Was Inconsistent and Unclear, and Response Did Not Fully
Follow This Guidance:

USPS Has Made a Number of Improvements in its Suspicious Mail Guidance,
but Some Key Elements Are Lacking:

Conclusions:

Recommendations for Executive Action:

Agency Comments and Our Evaluation:

Appendixes:

Appendix I: Scope and Methodology:

Appendix II: Comments from the U.S. Postal Service:

Appendix III: Contact and Staff Acknowledgments:

Related GAO Products:

Tables:

Table 1: USPS Facilities:

Table 2: Key USPS Guidance in Place on October 15, 2003 on Identifying
and Initially Responding to Suspicious Mail:

Table 3: Extent to Which Initial Response Actions Were in Accordance
with Suspicious Mail Guidance and Procedures for Handling Mail
Containing Hazardous Materials:

Table 4: Key USPS Guidance on Identifying and Responding to Suspicious
Mail Developed or Issued After October 2003 Incident:

Figures:

Figure 1: October 2003 Timeline of Greenville Incident:

Figure 2: Message on the Envelope:

Figure 3: Photo of the Sealed Vial Found Inside the Envelope:

Figure 4: Comparison of Instructions in Suspicious Mail Guidance:

Figure 5: USPS Three Ps Poster:

Abbreviations:

Three Ps: Package, People, and Plan:

CDC: Centers for Disease Control and Prevention:

DHS: Department of Homeland Security:

FBI: Federal Bureau of Investigation:

IEMP: Integrated Emergency Management Plan:

JTTF: Joint Terrorism Task Force:

SLAP: Shape, Look, Address, and Packaging:

USPS: United States Postal Service:

Letter:
July 19, 2005:

The Honorable Joseph I. Lieberman:
Ranking Minority Member:
Committee on Homeland Security and Governmental Affairs:
United States Senate:

Dear Senator Lieberman:

In fall 2001, five persons died from inhalation anthrax contracted from
contaminated letters delivered through the U.S. mail system.[Footnote
1] After the anthrax attacks, the frequency of incidents involving
suspicious packages or powder spills increased dramatically, due partly
to anthrax hoaxes as well as concerns over leakages from mail that had
previously been handled routinely. Since October 2001, over 16,000 such
incidents have occurred at postal facilities. These incidents have
posed a challenge to the U. S. Postal Service (USPS) as well as to law
enforcement and public health agencies at all levels of government. The
Postal Service has emphasized to its employees to be on the alert for
"suspicious mail" that may pose a threat and has developed guidance for
them on how to identify and respond to such mail, in order to protect
them and the public from potential harm. Suspicious mail consists of
envelopes or packages that have characteristics that indicate they may
have dangerous contents, such as a bomb, a radiological substance, or a
biological or chemical agent.[Footnote 2] The Postal Service has made a
commitment to continuously improve its processes related to anthrax and
other biohazards, including its guidance for identifying and responding
to suspicious mail.

In October 2003, an envelope marked "Caution: Ricin Poison" was
discovered at an airmail facility in Greenville, South Carolina. Ricin
is a biotoxin derived from castor beans that, in certain forms, can
cause death within 36 to 72 hours after exposure. Agencies involved in
responding to the October 2003 incident included the Postal Service,
the South Carolina Department of Health and Environmental Control, the
Centers for Disease Control and Prevention (CDC), the Department of
Homeland Security (DHS), and the Federal Bureau of Investigation (FBI).
In November 2003, an envelope containing a substance initially
suspected of being ricin was discovered at a White House mail
processing facility.[Footnote 3]

Citing concerns about the responses to the October and November 2003
incidents, particularly the timing of response actions, you asked us to
examine these responses. As agreed with your staff, we plan to issue a
separate report on the November 2003 incident later this year. To
provide you with information on the response to the October 2003
incident, we focused on the following questions:

* In responding to the incident, what actions did the Postal Service,
CDC, and other agencies take to protect the health of postal employees
and the public, and when did they take these actions?

* During the incident, what Postal Service guidance for identifying and
responding to suspicious mail was in place, and to what extent were
actions by postal personnel in accordance with this guidance?

* What changes has the Postal Service made in this guidance since the
incident, and to what extent does current guidance address issues
raised by the incident?

To address these questions, we interviewed federal and state officials
involved in the response to this incident and obtained and reviewed
agency documents to determine the roles and response actions of the
agencies involved. We also analyzed Postal Service guidance in place at
the time that was related to suspicious mail, including guidance on
identifying suspicious mail and taking initial response actions;
procedures for identifying, handling, and responding to hazardous
materials in the mail; and Postal Service guidance on communicating
with employees and unions that could pertain to suspicious mail
incidents. We compared actions taken by postal personnel during the
incident with this guidance. We also interviewed union officials
representing workers at the Greenville airmail facility to obtain their
perspective on response actions by postal personnel. In analyzing
whether actions taken by postal personnel were in accordance with
existing guidance, we focused on actions taken from the initial
discovery of the envelope until its removal from the facility, except
for communications with employees and unions, which we covered until
final testing results on the envelope and its contents were available.
We reviewed current and planned Postal Service guidance related to
suspicious mail and compared it with guidance in place during the
incident to identify changes and the extent to which current guidance
addresses issues raised by the incident. To assist in this analysis, we
reviewed previous GAO work regarding the anthrax incidents, pertinent
literature and previous GAO work on risk management and risk
communications, and guidance produced by CDC, the General Services
Administration, and others on mail security and responding to
biological threats in the mail. We performed our work from June 2004
through May 2005 in accordance with generally accepted government
auditing standards. Further details about our scope and methodology
appear in appendix I.

Results in Brief:

The Postal Service and other agencies took a number of actions to
protect the health of postal employees and the public after the
envelope in question was discovered at the airmail facility in
Greenville on October 15, 2003. Postal personnel identified the
envelope as suspect shortly after midnight and took some initial
actions in response, including moving it to a room away from employees
and double-bagging it. The manager of the facility called postal
inspectors, who are responsible for initially assessing the threat
posed by suspicious mail, after arriving at work the following morning,
but did not speak with an inspector until about 12 hours after the
envelope had been discovered. The manager called emergency responders
shortly thereafter based on the inspector's advice. Law enforcement
officers conducted a threat assessment, and then immediately
transported the bagged envelope to a law enforcement laboratory for
further assessment. This assessment revealed that a metal vial was
inside the envelope. On the morning of October 16, a laboratory of the
South Carolina health department received the envelope and vial for
testing. This laboratory determined that the risk of exposure was low
because the vial was well-sealed, and it conducted some initial tests
of the substance inside the vial. However, the laboratory did not have
the capability to test for ricin at that time and agreed with CDC to
send a sample to CDC for testing on the following Monday, October 20,
so that the sample would not arrive during the weekend. CDC received
the sample on October 21 and, on that same day, performed tests for
ricin and determined that ricin was present in the substance.
Subsequently, various federal and state agencies cooperated in
developing and implementing the response, which included monitoring the
health of employees and the public, sampling the facility, and
communicating information to employees and unions. Samples taken at the
facility tested negative for ricin, and the public health response
ended on October 29, with no confirmed cases of ricin exposure.

In October 2003, the Postal Service had in place several guidelines on
identifying and responding to suspicious mail, but postal personnel did
not fully follow this guidance during the initial response to the
discovery of the envelope. A lack of consistency and clarity in this
guidance, as well as a lack of clarity in some related procedures, may
have been a contributing factor for their actions. For example, the
instructions in the suspicious mail guidelines were not consistent, and
the types of situations they applied to may not have been clear to
employees. In addition, the Postal Service had related procedures for
identifying and handling routine mail containing hazardous materials
that cited some characteristics to identify this type of mail that were
similar to characteristics of suspicious mail. During the incident,
although the envelope had some characteristics of suspicious mail,
personnel initially followed the procedures for handling mail
containing hazardous material because such mail typically has warning
labels and the message on the envelope appeared to constitute such a
warning label. However, these hazardous material procedures do not
instruct postal personnel to take some precautions, such as not
handling the mail piece and calling postal inspectors first in all
instances, which are recommended in the suspicious mail guidance and
are designed to protect employees. In October 2003, the Postal Service
also had some guidance in place on communicating with employees and
unions regarding suspicious mail incidents and its efforts to inform
them about this incident generally followed this guidance. However, a
lack of specific instructions in this guidance--on who should provide
and receive information and when information should be provided--may
have contributed to some communications issues that arose. For example,
union officials cited concerns that local unions were not notified
until 7 days after the discovery of the envelope, after testing results
were available.

Since the incident in Greenville in October 2003, USPS has made a
number of changes in its guidance on identifying and responding to
suspicious mail that have improved its consistency and clarity,
therefore addressing some of the issues raised by the incident. For
example, the Postal Service has sought to clarify the process for
identifying and responding to suspicious mail and raise employee
awareness of this process by developing and issuing new simpler and
standardized guidance. A main goal of this effort has been to ensure
that employees are protected from possible biological and chemical
threats in the mail. However, current guidance does not fully address
issues raised by the incident because some key elements are lacking. In
particular, the Postal Service has not provided guidance to employees
on actions to take if a mail piece has characteristics of both
suspicious mail and mail containing hazardous material. It has also not
provided training for managers and supervisors on suspicious mail that
presents all the guidance they may need to make appropriate decisions.
Without this additional guidance, postal personnel may have difficulty
in some cases, as occurred in the Greenville incident, in deciding
whether a mail piece is suspicious and whether response actions, such
as shutting down equipment and calling postal inspectors, are
warranted. Furthermore, the Postal Service has not provided explicit
guidance to its managers on communicating with employees and unions
regarding suspicious mail incidents. Such communications are
particularly important in instances in which mail suspected of
containing a biological or chemical agent is sent for testing. Without
such guidance, employees and unions may not receive timely information
regarding the situation and may not feel confident that they have been
adequately informed.

We are making several recommendations to further improve the Postal
Service's guidance related to suspicious mail, to help ensure that
postal personnel are prepared to respond to future incidents involving
mail that may contain biological or chemical agents. Specifically, we
are recommending that the Postal Service (1) provide guidance to
employees on the response actions to take in the event a mail piece has
characteristics of both suspicious mail and mail containing hazardous
material, (2) expand its training for managers and supervisors on
suspicious mail, and (3) provide more explicit guidance to managers on
communicating with employees and unions regarding incidents in which a
mail piece is sent for testing.

We requested comments on a draft of this report from the Postal
Service, CDC, DHS, the FBI, and the two postal unions that represent
employees of the Greenville airmail facility (the American Postal
Workers Union and the National Postal Mail Handlers Union). The Postal
Service provided written comments generally agreeing with our
recommendations and said that, in response, it intends to implement a
number of improvements in its suspicious mail guidance, including
expanded training for employees. These comments are reprinted in
appendix II. The Postal Service also provided some technical comments,
which we incorporated. The FBI provided technical comments, which we
incorporated. DHS, CDC, and the postal unions did not provide comments
on the draft.

Background:

Ricin is a poison derived from the beans of the castor plant.[Footnote
4] Exposure to ricin in high enough doses can cause organ failure and
death. Initial symptoms may develop within 8 hours of exposure. There
is currently no approved treatment or cure, such as an antidote, for
ricin exposure in humans. However, the symptoms can be managed with
medical intervention, such as respiratory support, if they are
recognized early and the dose is not lethal.

The Greenville, South Carolina-airmail facility where the envelope
marked "ricin" was discovered in October 2003 is part of the national
postal network of USPS. This network includes thousands of facilities
across the United States that process and distribute mail, as shown in
table 1. USPS processes and distributes over 200 billion pieces of mail
annually.

Table 1: USPS Facilities:

Facility type: Processing and Distribution Centers and Facilities;
Number: 348;
Description: Process and dispatch incoming and outgoing mail for a
designated service area.

Facility type: Airmail Centers and Facilities;
Number: 78;
Description: Receive, distribute, and dispatch mail transported
principally by air.

Facility type: Bulk Mail Centers;
Number: 21;
Description: Process and distribute bulk standard mail and parcels.

Facility type: Priority Mail Processing Centers;
Number: 12;
Description: Process priority mail.

Facility type: Post Offices, Stations, and Branches;
Number: 37,159;
Description: Collect, distribute, and deliver mail.

Source: USPS.

[End of table]

The Postal Inspection Service (Inspection Service) provides for the
security of the mail and the enforcement of federal postal laws. The
service employs approximately 1,900 fact-finding and investigative
postal inspectors and 950 uniformed postal police officers. In the
years since the anthrax attacks, the service--along with USPS as a
whole--has faced the challenge of responding to a large increase in
suspicious mail incidents that have caused disruptions of postal
operations. In fiscal year 2002, when the Inspection Service began
systematically collecting statistics on suspicious mail incidents,
about 13,500 such incidents occurred at postal facilities.
Subsequently, the number of such incidents significantly declined, to
about 800 in fiscal year 2003 and 1,500 in fiscal year 2004. According
to postal officials, these incidents have often involved leakages of
routine substances, such as sand or talcum powder, from mail pieces.

Since the anthrax attacks in the fall of 2001, the Postal Service has
made a number of efforts to manage risks posed to the mail system by
biological and chemical agents, such as anthrax and ricin.[Footnote 5]
A main effort has been developing additional guidelines for employees
on identifying and responding to suspicious mail, including mail that
may pose a biological or chemical threat. Other main efforts include:

* developing an "all-hazards" emergency response plan for managing
natural and man-made emergencies;

* installing biohazard detection systems at some processing facilities
and developing and implementing related procedures and training of
personnel;[Footnote 6] and:

* creating an Emergency Preparedness Office and deploying emergency
managers at some USPS facilities.

When an incident involving suspicious mail occurs at a USPS postal
facility, personnel at the affected facility may contact postal
inspectors, local police, and local fire department hazardous materials
units for assistance. In addition, depending on the circumstances and
severity of the incident, state and local health authorities, the FBI,
and CDC might become involved. These local, state, and federal entities
each conduct activities according to their function, such as threat
assessments and criminal investigations, testing to identify unknown
biological substances, and health surveillance of potentially exposed
persons. In certain circumstances, such as when more than one federal
agency is involved in the response, DHS becomes involved and
coordinates the federal response.

USPS, the State Health Department, and CDC Took Actions to Protect the
Health of Employees and the Public:

Following the discovery at the Greenville airmail facility of the
envelope marked "Caution: Ricin Poison" shortly after midnight on
October 15, 2003, the Postal Service and other agencies took a number
of response actions to protect the health of postal employees and the
public. (See fig. 1.) Postal personnel took some initial actions,
including isolating the envelope in a room away from employees, double-
bagging it, and calling the Inspection Service. However, the facility
manager did not speak with an inspector until about noon on that day,
and called emergency responders shortly after, based on the inspector's
advice. Local law enforcement and fire department personnel responded,
along with members of an FBI joint terrorism task force (JTTF) and a
postal inspector.[Footnote 7] A threat assessment was conducted and the
bagged envelope was then immediately transported to a law enforcement
laboratory for further assessment. This assessment revealed that a
metal vial was inside the envelope. On the morning of October 16, a
laboratory of the South Carolina health department received the
envelope and vial for testing. This laboratory determined that the risk
of exposure was low, because the vial was well-sealed, and conducted
some initial tests of the substance inside the vial. However, the
laboratory did not have the capability to test for ricin at that time
and agreed with CDC to send a sample to them for testing on Monday,
October 20, so that the sample would not arrive during the weekend. CDC
received the sample on October 21 and, on that day, confirmed that
ricin was present in the substance. Subsequently, various federal
agencies, as well as the state health department, coordinated in
developing and implementing the response. CDC conducted sampling at the
facility and found no evidence of ricin contamination. The state health
department and CDC monitored the health of employees and the public and
found no cases of ricin exposure. Finally, the facility manager briefed
employees on the incident on October 15 and Postal Service headquarters
prepared talks on the testing results, which were delivered to
employees and unions on October 22 and 23.

Figure 1: October 2003 Timeline of Greenville Incident:

[See PDF for image]

[A] The envelope had previously been double-bagged by postal personnel.

[End of figure]

USPS Personnel Discovered and Initially Responded to the Suspicious
Envelope on October 15:

About 12:15 a.m., on October 15, 2003, an employee at a postal airmail
facility in Greenville, South Carolina, discovered a standard business
size envelope, measuring 4 inches by 9 inches, on a mail processing
machine. The employee noticed that the envelope bore only a written
warning on the outside of the envelope and had no postage, addressee or
zip code, or return address. (See fig. 2.)

Figure 2: Message on the Envelope:

[See PDF for image]

Note: GAO re-created the original photo provided by the FBI in order to
optimize the appearance of the image.

[End of figure]

The employee removed the envelope from the mail processing machine, set
the envelope aside on a tray and finished processing the bundle of mail
that had accompanied the envelope. Within 10 minutes after discovering
the envelope, the employee took the tray containing the envelope to the
shift supervisor who was at the supervisory console, which was situated
between 30 and 40 feet away from the employee's workstation.

Being cautious and a bit uncertain, the supervisor had the area
cordoned off with orange cones and tape, and decided to evacuate the
facility. At 12:30 a.m., he instructed the 20 employees in the building
to evacuate the facility and called the facility manager at home around
12:40 a.m. During the phone call, the facility manager asked the shift
supervisor if the envelope was damaged, showed visible signs of
leakage, and whether suspicious odors were present. The shift
supervisor told the manager that the envelope did not exhibit any of
these characteristics. According to the facility manager, the
supervisor instructed the employee who had discovered the envelope to
wash her hands.

The facility manager told us that, at the outset, nobody knew exactly
what ricin was and, during the telephone conversation, the shift
supervisor suggested that it might be rat poison. At the instruction of
the facility manager, the tray containing the envelope was removed from
the workroom and put into the conference room next to the facility
manager's office. Shortly thereafter, the evacuation was called off and
employees returned to work until the shift ended at approximately 4:30
a.m. that morning.

The Inspection Service and Emergency Responders Became Involved 12
Hours after the Discovery:

About 7 hours after the envelope was first discovered, at around 7:30
a.m., the facility manager arrived at the facility. He inspected the
envelope about 8:00 a.m. At around 8:10 a.m., he called the local
safety officer, who advised him to contact the Inspection
Service.[Footnote 8] The safety officer also called the postal service
team responsible for responding to spills and leaks from a nearby
larger facility and asked them to report to the facility. At
approximately 9:00 a.m., this team arrived at the facility. Wearing
protective gear, the team retrieved the envelope from the conference
room, double-bagged it, and moved it to a secure room across the hall.
The team then locked the door and placed "Do Not Enter" signs on the
front.

Between 9:00 a.m. and noon, the facility manager placed a total of
three calls to the Inspection Service, including two calls to the
office in Greenville and one to the office in Charlotte, North
Carolina. The facility manager made the first call about 9:00 a.m. to
the Inspection Service office in Greenville. The inspector at the time
was out responding to a robbery investigation, so the facility manager
left a message. Later that morning, at 11:00 a.m., the facility manager
placed another call to the Inspection Service, this time to the
Charlotte office. Again, he was not able to reach an inspector, but
instead left a message that a suspicious mail piece had been discovered
in Greenville. According to the inspectors from Charlotte and
Greenville, neither of these two messages indicated that the situation
was urgent. According to the facility manager, he stated in his
messages what was written on the envelope but probably mispronounced
the word "ricin."

At noon, about 12 hours after the envelope had been first discovered,
the facility manager made another call to the Inspection Service office
in Greenville. This time he spoke with an inspector, who advised him to
call emergency responders. He did so, and at approximately 1:00 p.m.,
these responders, members of local law enforcement and the hazardous
materials unit of the fire department, arrived at the facility. At 1:20
p.m. the fire department evacuated the building.

At 1:50 p.m., an FBI agent and a county law enforcement officer,
members of the FBI's Joint Terrorism Task Force in the Greenville area,
responded to the incident.[Footnote 9] An inspector from the Greenville
Inspection Service office arrived at about the same time. Law
enforcement officials conducted a threat assessment, removed the bagged
envelope from the facility, and immediately transported it to a law
enforcement laboratory for further assessment. This assessment revealed
that the envelope contained a metal vial and a threatening letter
addressed to the Department of Transportation.[Footnote 10] (See fig.
3.)

Figure 3: Photo of the Sealed Vial Found Inside the Envelope:

[See PDF for image]

[End of figure]

According to the Inspection Service, the following morning inspectors
began tracking the path that the envelope may have taken before it was
discovered in the facility. This was done to determine how the envelope
arrived at the facility, whether it had possibly passed through another
facility, and whether it had potentially exposed other postal employees
or the public. However, the Inspection Service concluded that the
envelope had been discovered before it entered the mail stream because
it was not postmarked at the time of discovery.

According to USPS officials in Greenville, the facility manager and
shift supervisor informed employees of the situation as they reported
for the next work shift that afternoon. The facility manager told us
that this information was communicated in a talk that supervisors
deliver daily to employees and that normally consists of announcements
regarding operations. Also, according to the manager, he told employees
to let him know if they showed any signs of illness, based on the
advice of the FBI. The manager also told us that, sometime between
October 15 and 21, he found information on ricin on CDC's Web site,
printed copies of this information, and made them available to
employees and union representatives. He told us that he also shared
this information verbally with employees.

Public Health Officials Performed Tests from October 16 to 21:

At approximately 10:00 a.m. on October 16, 2003, South Carolina
Department of Health and Environmental Control's public health
laboratory, part of the CDC's Laboratory Response Network, received the
envelope, letter, vial and substance for testing.[Footnote 11] Using a
standard "all agents" testing approach, the laboratory tested for a
number of agents, including anthrax, but did not have the capability at
that time to perform tests for ricin. At this point of the response,
CDC was serving as an advisory agency to the lab. On Friday, October
17, the state laboratory agreed with CDC to send a portion of the
substance to CDC in Atlanta to test for ricin on the following Monday,
October 20, 2003. The state lab completed its testing on October 20 and
sent a sample of the substance to CDC on that date via overnight mail.

State laboratory officials told us that they did not send a sample of
the substance to CDC for ricin testing earlier because they believed
the risk of exposure was low, since the substance was contained in a
well-sealed metal vial that would prevent any amount of the substance
from escaping. The sealed nature of this vial led laboratory officials
to assume that there was time to work with the substance and make a
thorough and definitive assessment of what it was. The substance itself
appeared to be in a form that could not easily be dispersed and there
had been no reported symptoms of exposure to date. Also, CDC had asked
the laboratory officials to send the sample to them via overnight mail
on Monday rather than Friday, to ensure that it would be promptly
received and tested upon arrival. CDC officials explained to us that
had the public health threat been higher that they would have called up
their staff to be present during the weekend to receive and test the
sample.

On October 21, at about 10:20 a.m., about 6 days after the envelope had
first been discovered, CDC received the sample and began testing.
Around 3:45 p.m., the CDC lab confirmed the presence of ricin toxin in
the sample. CDC officials explained to us that, although the substance
had tested positive for ricin, they believed that it posed a low public
health risk because it was in a form that would be unlikely to affect
employees who might have come in contact with the envelope. Also, it
had been securely contained inside the metal vial and there was no sign
of leakage.

Multiple Agencies Responded from October 21 to 29:

Following CDC's testing, various federal and state agencies held
discussions, through teleconferences, to determine the appropriate
response. The participants in these interagency teleconferences
included officials of the Postal Service, the Inspection Service, CDC,
DHS, FBI, and the South Carolina health department, as well as other
South Carolina officials.[Footnote 12] The first teleconference was
held on October 21, 2003, at about 5:00 p.m. During this
teleconference, USPS told participants that no illnesses among
employees had been reported. In this teleconference and in subsequent
ones later that evening and the following day, the participants
discussed and agreed upon response actions to protect the health of
postal employees and the public, including monitoring the health of
facility employees and the public in the area to check for illnesses
that could indicate ricin poisoning, sampling the facility to determine
whether it had been contaminated, and communicating with postal
employees about the situation. CDC officials explained to us that,
although they believed that the substance that had been in the envelope
did not pose a serious public health threat, the decisions to monitor
the health of postal employees and the public and to sample the
facility had been made in order to be prudent.

Mid-afternoon on October 22, the state and local health departments
began interviewing employees at the Greenville airmail facility to
check for symptoms of ricin exposure and to answer questions. CDC
personnel were on hand to assist in this effort. At 3:00 p.m., mail
processing at the facility stopped and no mail was allowed to leave the
premises. At 6:00 p.m., a talk, prepared by USPS headquarters with the
advice of CDC and the state health department, was given to Greenville
postal employees informing them about the situation. This talk
explained that the facility had been closed for testing and that the
envelope that had been discovered on October 15 had contained a vial
with a substance that had tested positive for ricin at CDC. This talk
also stated that the vial had been well-sealed and that there had been
no indications of employee exposures connected to the incident.

CDC, the state health department, the FBI, and the Inspection Service
participated in the talk in Greenville and answered employee questions
and concerns. Local union representatives were provided with the
information in the talks prior to their delivery. The information in
the Greenville talk was provided by USPS headquarters to all employees
nationwide that evening and the following morning, in a news
announcement and a talk for delivery to all employees.

In the early morning hours of October 23, 2003, CDC personnel collected
swab and vacuum samples from the facility, sending them to CDC for
analysis at approximately 6:30 a.m. About 3:30 p.m., CDC reported that
all samples taken from the facility had tested negative for ricin. At
6:00 p.m., a talk, prepared by USPS headquarters, was provided to
Greenville employees informing them of these results and that the
facility would reopen on Friday, October 24, 2003. This talk emphasized
appropriate steps to follow when encountering a suspicious package.
USPS headquarters also provided this information to all employees
nationwide in a news announcement issued about the same time. On
October 24, 2003, the facility reopened for operations.

On October 21, after CDC reported its testing results, state public
health officials alerted area hospitals, private practice physicians,
and the state poison control center to be on the lookout for symptoms
associated with ricin exposure. CDC also checked poison control center
records to see if any cases that could indicate ricin poisoning had
been reported. On October 22, state and local health officials, with
assistance from CDC, interviewed all employees at the Greenville
airmail facility to check for symptoms of ricin exposure. At that time,
they determined that no employees had any health complaints that could
be reasonably related to ricin exposure. In addition, the state health
department and CDC conducted statewide monitoring for illnesses that
could indicate ricin exposure and distributed a written description of
ricin poisoning to area hospitals, emergency rooms and other health-
care providers. Medical surveillance continued until October 29, 2003,
approximately 14 days after the envelope was first discovered, with no
confirmed cases of ricin exposure.

USPS Guidance Was Inconsistent and Unclear, and Response Did Not Fully
Follow This Guidance:

In October 2003, the Postal Service had in place several guidelines on
identifying and responding to suspicious mail but these guidelines were
not entirely consistent or clear. In addition, the Postal Service had
procedures for identifying and handling routine mail containing
hazardous materials that cited some characteristics to identify this
type of mail that were similar to characteristics of suspicious mail.
During the incident, postal personnel did not fully follow the
suspicious mail guidelines and a contributing factor may have been the
lack of consistency and clarity in these guidelines, as well as a lack
of guidance on what to do if a mail piece has characteristics of both
suspicious mail and mail containing hazardous material. For example,
personnel initially followed the procedures for handling mail
containing hazardous material because this type of mail typically has
warning labels and the message on the envelope appeared to constitute
such a warning label. However, these procedures do not instruct postal
personnel to take some precautions, such as not handling the mail piece
and calling postal inspectors first in all instances, which are
recommended in the suspicious mail guidance. These precautions are
designed to protect employees from exposure to possible biological or
chemical threats and to obtain the early involvement of those with
expertise who can assess the threat posed by a suspicious mail piece.
Finally, the Postal Service had guidance on communicating with
employees and unions regarding suspicious mail incidents. While efforts
by the Postal Service to communicate with employees and unions about
this incident generally followed this guidance, a lack of explicit
instructions in the guidance on providing information to employees and
unions may have contributed to some communications issues that arose.

USPS Had a Number of Guidelines for Identifying and Responding to
Suspect Mail but They Were not Consistent or Clear:

The Postal Service's suspicious mail guidelines in October 2003 had
been developed or updated following the fall 2001 anthrax incidents to
ensure that postal personnel took appropriate precautions upon
discovering a suspicious package or envelope. However, these guidelines
contained instructions that were not entirely consistent. Also, the
types of scenarios they applied to may not have been entirely clear to
employees and some appeared to apply only to incidents involving
suspicious powders. Furthermore, some related procedures for
identifying and segregating mail containing or that could contain
hazardous materials did not clearly specify what employees should do if
a mail piece identified as possibly containing a hazardous material
also had characteristics of suspicious mail. Finally, USPS had general
guidelines regarding communicating with employees and unions, but these
guidelines did not clearly specify who should provide and receive
information on suspicious mail incidents or when information should be
provided. According to GAO's internal control standards, appropriate
policies and procedures should exist with respect to each agency
activity.

Guidelines for Identifying and Initially Responding to Suspicious Mail:

At the time of the incident in Greenville, key Postal Service guidance
on suspicious mail included two documents--"decision trees" and a
poster--as well as a training exercise. (See table 2.) The decision
trees guideline and the training exercise were mainly aimed at managers
and supervisors, while the poster was aimed at all postal employees as
well as the public. Both the facility manager and shift supervisor had
undergone the training exercise, which focused on handling incidents
involving a questionable substance leaking from a mail piece.

Table 2: Key USPS Guidance in Place on October 15, 2003 on Identifying
and Initially Responding to Suspicious Mail:

Type of guidance: Guidance documents.

Type of guidance: Decision trees;
Intended audience: Guidance documents: Managers and supervisors;
Date issued or updated: Guidance documents: October 2001.

Updated in March 2003;
Description: Guidance documents: Presented separate sets of actions to
take, in a flowchart format, in incidents involving a suspicious
unopened/sealed mail piece and in incidents involving an open mail
piece leaking a suspicious powder.[ A] Also, included different actions
for small and large facilities to take during either type of incident.
Developed based on CDC advisories.

Type of guidance: Suspicious mail poster;
Intended audience: Guidance documents: All employees and the public;
Date issued or updated: Guidance documents: October 2001.

Updated in March 2003;
Description: Guidance documents: Portrayed, in a one-page poster with a
photo, how to identify a suspicious mail piece and key actions to take
upon discovery. Also, presented additional separate guidance for
situations involving a suspected bomb, radiological threat, or
biological or chemical threat.

Type of guidance: Training.

Type of guidance: Suspicious powder tabletop exercise;
Intended audience: Training: Managers, supervisors, and support staff;
Date issued or updated: Guidance documents: April 2003;
Description: Guidance documents: Presented actions to take in incidents
involving a suspicious powder leaking from a mail piece. Consisted of a
series of scenarios portraying phases of a hypothetical incident and
active exercises in responding to these scenarios. Included the
decision trees.

Source: GAO analysis of USPS suspicious mail guidance.

Note:In addition, in November 2001, USPS issued interim guidelines for
responding to an anthrax release that covered a range of response
activities--including sampling, analysis, and decontamination--and also
included guidance on the initial response to a suspected incident.

[A] According to USPS officials, its Mail Security Task Force, which
includes representatives of employee unions and management
associations, reviewed these guidelines during their development.

[End of table]

The guidance documents and training exercise described characteristics
for employees to look for to detect "suspicious" packages and envelopes
that could potentially pose a threat, such as a bomb or a biological
threat. These characteristics included the following:

* Lopsided or uneven.

* Powdery substance on the outside.

* Odors, discoloration, or oily stains.

* Excessive postage or tape.

* No return address.

* Handwritten or poorly typed address.

* Marked with restrictions, such as "Personal," "Confidential," or "Do
Not X-Ray."

* Threatening message.

However, the suspicious mail characteristics in these guidelines were
not consistent and none of the guidelines had a complete list of
suspicious mail characteristics. (See fig. 4.) Some characteristics
were cited in only one or two of these guidelines. For example, only
the decision trees cited "threatening message" as a characteristic of
suspicious mail and only the poster cited excessive tape. Also, the
poster and training exercise cited restrictive markings as a
characteristic of suspicious mail while the decision tree did not.

The guidance documents and training exercise also provided instructions
on initial steps to take upon discovering a suspicious mail piece. (See
fig. 4.) In general, they advised isolating the mail piece and
notifying others with expertise in assessing threats associated with
mail pieces, such as postal inspectors and local law enforcement.
Recommended initial steps were not consistent, however. The decision
trees, intended for use by USPS managers and supervisors, advised not
handling the mail piece and notifying the supervisor and Inspection
Service before contacting the local police and hazardous materials
unit. The poster, intended for use by the public as well as postal
employees, recommended handling a suspicious package or letter with
care and calling local law enforcement. The poster also advised more
precautions if a biological or chemical threat was suspected, including
not handling the mail piece and calling police, postal inspectors, and
the local hazardous materials unit. The training exercise, intended for
USPS managers and supervisors, focused on suspicious powder incidents
and recommended response steps similar to those in the decision trees.

Figure 4: Comparison of Instructions in Suspicious Mail Guidance:

[See PDF for image]

Note: Shaded boxes indicate that similar information was not found in
identified guidance.

[A] These are steps for small offices. USPS has separate training for
large offices. Also, these represent key steps presented in the
training that are similar to those in the other guidelines. The
training also provided more detailed guidance on actions to take in
response to a suspicious powder incident.

[B] The subsequent steps are for small facilities, unless otherwise
noted. The decision tree for large facilities included additional
response actions for the supervisor.

[C] According to a USPS official, the basic intent of the instruction
to contact the postmaster is to contact the next level of management,
which for the Greenville airmail facility would be the senior plant
manager.

[D] The safety office supports management by monitoring and assessing
safety hazards and potentially unsafe conditions and providing support
to spill and leak teams, among other things.

[End of figure]

The types of scenarios these guidelines applied to may not have been
entirely clear to employees. While the decision trees provided the most
complete guidance on responding to suspicious mail incidents involving
nonleaking as well as leaking mail, at the time of the incident the
circumstances under which they were intended to be used may have been
unclear. The manager of the Greenville airmail facility told us that,
at the time of the incident, he thought the decision trees were for
anthrax-related emergencies only. When the Postal Service first issued
this guideline in October 2001, it noted that it applied to scenarios
involving the potential release of anthrax spores as well as "similar
bioterrorist incidents." However, the March 2003 version of this
guideline was titled "Updated Decision Trees for Suspicious Mail Pieces
and a Powder Release from a Mail Piece" and Postal Service management
indicated that it could be used in various situations involving a
suspicious mail piece.[Footnote 13] Furthermore, while the poster
recommended more precautionary steps in instances in which a biological
or chemical threat was suspected, postal officials have acknowledged
that it could be difficult for employees to determine if a mail piece
potentially posed such a threat if it was not leaking a substance.
Finally, the training focused on scenarios involving the discovery of a
suspicious powder and therefore its applicability to other types of
scenarios may not have been clear.

Procedures for Identifying, Handling, and Responding to Hazardous
Materials in the Mail:

In addition to the guidelines described above, which were aimed at
taking precautions against possible threats in the mail, USPS had
"hazardous material handling" procedures that instructed employees to
identify routine mail containing hazardous material that is properly
packaged and labeled, as well as mail that may contain hazardous
material and that is not properly packaged and labeled, and separate
such mail from other mail by moving it to another area.[Footnote 14]
Among the characteristics that employees are trained to look for, to
detect mail containing or that may contain hazardous material, are
warning labels and stains, leakage, or an unusual odor. These
characteristics are similar to ones employees are told to look for in
detecting suspicious mail. However, these hazardous material handling
procedures do not instruct employees on what to do if an envelope or
package has characteristics of both suspicious mail and mail containing
or that may contain hazardous material.

USPS also had procedures and related guidelines, generally issued prior
to the anthrax incidents, on responding to the release of hazardous
materials, including releases of powders or other substances from mail
pieces. These documents described the role of spill and leak teams,
generally located in large postal facilities, which are trained to
respond to releases and to determine whether an emergency exists. The
decision trees also indicated that, in large facilities, these teams
could respond to suspicious mail incidents without spills or leaks. The
Greenville airmail facility is considered to be a small facility, with
about 35 employees, but did use the spill and leak team from a nearby
large plant in this incident.

In emergency situations, USPS facilities were expected to follow their
"emergency action plans," which outline actions to take, such as
evacuating employees and calling local first responders, in a variety
of emergency situations. The Greenville emergency action plan included
initial actions to take in response to a hazardous material release and
a suspected anthrax release, but not for other types of suspicious mail
situations. In a bulletin to Postal Service management following the
incident, USPS stated that these plans must include instructions for
responding to suspicious mail pieces, including guidance on initial
action, isolation, evacuation, and notifications.

Guidance on Communicating with Employees and Unions:

At the time of the incident, the Postal Service's suspicious mail
guidance contained some recommendations regarding communications with
employees and unions. In an e-mail message accompanying the March 2003
decision trees, USPS headquarters stated that communications are a
vital part of the process for responding to suspicious mail and that
"employees and their representatives must be kept informed at all
stages, including the final results and resolution of the incident."
Also, the suspicious powder training exercise recommended that, in
suspicious powder incidents in which emergency responders have become
involved, management should provide unions and employees with current
information on the situation on a regular frequency.[Footnote
15]However, this guidance did not specify who is authorized to provide
information, when information should be provided and to whom, and what
types of information should be shared.

In addition, since the late 1990s, postal managers in USPS's Eastern
area, which includes South Carolina, have been encouraged to hold brief
discussions with employees at the beginning of each workday regarding
workplace performance and business updates. The purpose of this
practice is to increase communication with employees and, according to
postal officials, such discussions could include providing information
on suspicious mail incidents.

Suspicious Mail Guidance Was Not Always Followed:

During the incident, personnel at the Greenville airmail facility
followed some, but not all, of the steps in the suspicious mail
guidance. In particular, the envelope was moved several times,
employees returned to the work area where the envelope had been, and
notifications of the Inspection Service and emergency responders were
not made in the order recommended and were delayed. Because the
envelope had some characteristics of mail containing hazardous material
and the personnel did not know what ricin was, they also followed
hazardous material handling procedures. (See table 3.) Greenville
postal management explained that, since the envelope also had some
characteristics of suspicious mail, they were uncertain how to respond
and were trying to determine the best course of action to take. Lack of
clarity and consistency in the suspicious mail guidance as well as a
lack of guidance on what to do if a mail piece has characteristics of
both suspicious mail and mail containing hazardous materials may have
contributed to this uncertainty and to the fact that some of the steps
in the suspicious mail guidance were not followed. Since the suspicious
mail guidelines take a precautionary approach to protect employees from
possible threats, including biological and chemical agents, if a mail
piece contained such an agent, not following these guidelines could
result in employees being exposed to the agent.

Characteristics of the envelope that were consistent with indicators in
the suspicious mail guidelines were no return address and a message
that could be considered threatening or restrictive: "Caution: RICIN
POISON. Enclosed in sealed container. Do not open without proper
protection." In addition, the facility manager told us that the lack of
an addressee and postage raised concerns.[Footnote 16] Furthermore, it
was likely that the envelope was lopsided, since it contained only the
threat letter and a vial the size of a "C" battery. However, the
message on the envelope, particularly the words caution and poison,
could also be interpreted as characteristics of mail containing
hazardous material since this type of mail typically has warning labels
and poison is a type of hazardous material.

Table 3: Extent to Which Initial Response Actions Were in Accordance
with Suspicious Mail Guidance and Procedures for Handling Mail
Containing Hazardous Materials:

Time period: 12:15 a.m to 1:00 a.m;
Actions taken: Employee separated envelope from other mail and brought
it to her supervisor;
Were actions in accordance with suspicious mail guidelines?: Yes -
poster[A];
No - decision tree[B];
Were actions in accordance with hazardous material handling
procedures?: Yes.

Actions taken: Time period: Supervisor isolated envelope, cordoned off
the area, and evacuated employees;
Were actions in accordance with suspicious mail guidelines?: Yes[C];
Were actions in accordance with hazardous material handling
procedures?: N/A.

Actions taken: Time period: Employee instructed to wash hands.[D];
Were actions in accordance with suspicious mail guidelines?: Yes;
Were actions in accordance with hazardous material handling
procedures?: Time period: N/A.

Actions taken: Time period: Based on instructions from the facility
manager, supervisor moved envelope to a conference room;
Were actions in accordance with suspicious mail guidelines?: No;
Were actions in accordance with hazardous material handling
procedures?: Yes.

Actions taken: Based on instructions from the facility manager,
supervisor allowed employees to return to work room;
Were actions in accordance with suspicious mail guidelines?: No;
Were actions in accordance with hazardous material handling
procedures?: Yes.

Time period: 8:00 a.m to 12:00 p.m;
Actions taken: Facility manager contacted:
* Safety officer at 8:10 a.m;
* Inspection Service at 9:00 a.m., 11:00 a.m. and 12:00 p.m. (left two
non-urgent messages but did not speak with inspector until noon);
* Postmaster[E] at 11:00 a.m;
* Local police at 12:00 p.m. (contacted after speaking with inspector);
Were actions in accordance with suspicious mail guidelines?: No (did
not call in order recommended and calls delayed);
Were actions in accordance with hazardous material handling
procedures?: N/A.

Actions taken: Spill and leak team examined scene at 9:00 a.m., double-
bagged the envelope, put it in a separate room, and put "Do Not Enter"
signs on the doors;
Were actions in accordance with suspicious mail guidelines?: Yes[F];
Were actions in accordance with hazardous material handling
procedures?: N/A.

Source: GAO analysis of actions taken during the response as well as
USPS suspicious mail guidance and hazardous material handling
procedures.

Note: N/A means that the action was not applicable to this type of
guidance.

[A]The poster indicates that suspicious mail should be handled with
care, but that if a biological or chemical threat is suspected for the
mail piece not to be handled.

[B] The decision tree calls for not handling suspicious mail further.
Training is not applicable for this action because the training calls
for not disturbing a suspicious powder and this incident did not have a
powder.

[C] The suspicious mail guidelines recommend moving employees to a
place of refuge, but do not call for evacuating the facility.
Supervisor took this action as an extra precaution.

[D] According to the facility manager, the supervisor told the employee
to wash her hands.

[E] The facility manager contacted the senior plant manager at 11:00
a.m. Although suspicious mail guidelines indicate that the postmaster
should be contacted, postal officials have told us that the basic
intent of this instruction is to contact the next level of management,
which, for the Greenville airmail facility, would be the senior plant
manager.

[F] However, spill and leak team members have stated that they were
told to respond in spite of concerns. Also, moving the envelope was not
in accordance with suspicious mail guidelines.

[End of table]

According to the facility manager, the employee who discovered the
envelope perceived it to be mail containing hazardous material, based
on the words "caution" and "poison" on the envelope. She then took
steps that followed USPS procedures for handling this type of mail. She
prevented the envelope from entering the mail stream by removing it
from the machine she was working on and notified her supervisor of her
discovery. The employee also segregated the envelope from other mail
when she brought it to her supervisor, who was located 30 to 40 feet
away. Notifying the supervisor was in accordance with guidance on
responding to suspicious mail, but handling and moving the envelope was
not in accordance with some of this guidance. (Although the decision
tree advised not handling a suspicious mail piece, the poster stated
that suspicious mail should be handled with care.) In addition,
according to the facility manager, the employee washed her hands on the
advice of the supervisor. This was in accordance with suspicious mail
guidelines.

The supervisor took actions that were in accordance with suspicious
mail guidelines. Specifically, the supervisor isolated the envelope and
prevented other employees from entering the area. He also evacuated the
facility as an additional precaution. According to the USPS after
action report for this incident, the supervisor was using knowledge
learned during the suspicious powder training exercise. According to
Greenville postal officials, the facility's emergency action plan,
which outlines evacuation procedures, was activated at this point.

The facility manager took some actions that were in accordance with the
hazardous material handling procedures as well as the suspicious mail
guidance, but did not fully follow the steps in the suspicious mail
guidance. While on the phone with the supervisor, the facility manager
decided that since the envelope was not leaking, employees could be
allowed back into the building. He explained that, at that point, he
did not know what ricin was and thought that the envelope could contain
hazardous material but was not properly labeled, so he had the envelope
segregated from other mail. Also, because the envelope indicated that a
poison was inside, he instructed that the envelope be moved to another
room, rather than placed in the designated area for such mail, as an
extra precaution. Once the envelope was moved to another room, the
employees were allowed to return to the facility. These actions were in
accordance with the hazardous material handling procedures, which
included instructions for segregating hazardous material mail in an
area away from work areas and traffic flows. However, suspicious mail
guidelines indicated that if something is suspicious, employees should
be kept in a place of refuge away from the mail piece until local
emergency responders arrive. Also, moving the mail piece was not in
accordance with suspicious mail guidelines. The suspicious mail
procedures take a precautionary approach in order to protect employees
from unknown threats, therefore, following hazardous material handling
procedures could unintentionally expose employees to a harmful
substance if a mail piece actually contained a threat and not routine
hazardous material.

When the facility manager observed the envelope after he reported to
work at about 7:30 a.m., he took an action that is not outlined in USPS
guidance. Because he still did not know what ricin was he consulted a
dictionary, which provided a brief description (a poisonous protein
from the castor bean), and then he contacted the local safety officer
for further assistance.[Footnote 17] By doing so, the facility manager
did not follow the order of notification outlined in the suspicious
mail guidance. The guidance specifies that the Inspection Service
should be notified first and then emergency responders. According to
the facility manager, he did not want to call the Inspection Service or
local emergency responders if the situation was something that could be
handled by facility personnel. The procedures for handling mail
containing hazardous materials state that the Inspection Service should
be contacted only when considered necessary and do not mention
contacting the safety officer.

The safety officer contacted the spill and leak team to respond to the
situation, which was in accordance with suspicious mail guidelines. The
spill and leak teams are USPS-facility based teams trained to respond
to routine spills and leaks in the postal system. Although there was no
spill or leak associated with this envelope, Greenville postal
officials told us that they called the spill and leak team to respond
as an extra precaution. According to Postal Service procedures for
these teams, they must initiate the facility's emergency action plan,
which includes evacuation and calling emergency responders, if they
encounter a material that is outwardly hazardous.[Footnote 18] One of
the team members, who may have had some knowledge of ricin based on
military training, voiced concerns to his supervisor about the
appropriateness of the spill and leak team responding to the
incident.[Footnote 19] The supervisor, acting on the team member's
concerns, contacted the safety officer to discuss the situation.
According to the safety officer, she offered to respond instead, since
she had the required training, but the supervisor of the team called
back afterward indicating that he and the team would respond. According
to the team members, they were told to respond in spite of their
concerns.

When the spill and leak team arrived at the facility, it double-bagged
the envelope and moved it to a separate room, where they isolated it by
closing the room and putting "Do Not Enter" signs on the doors. They
did not initiate the facility's emergency action plan. Some of these
actions are in accordance with the suspicious mail guidelines, which
call for the team to take defensive actions. However, moving the
envelope was not in accordance with these guidelines and the
information the one team member had about ricin should have been
considered in determining whether an emergency existed.

The facility manager did not attempt to contact the Inspection Service
until approximately nine hours after initial discovery, after speaking
with the safety officer, and made an additional attempt before actually
speaking with an inspector about 12 hours after the discovery. He did
not call the Inspection Service first, as recommended in the suspicious
mail guidelines. Hazardous material handling procedures stated that the
supervisor should call the Inspection Service "if necessary,"
concerning a mail piece that may contain hazardous material but that is
not properly labeled. Although the suspicious mail guidelines had no
references to how quickly contact with the Inspection Service should
occur after suspicious mail is discovered, a message to managers in
2002 on the identification and handling of suspicious mail included
instructions that the Inspection Service should be called immediately
after the identification of a suspicious mail piece. Upon receiving
calls regarding suspicious mail, postal inspectors conduct an initial
threat assessment and provide advice to facility managers regarding
immediate actions to be taken, such as whether to call emergency
responders.

USPS officials, at both the local and headquarters levels, acknowledge
that not contacting the Inspection Service immediately was not an
optimal way to handle the situation. Inspection Service officials told
us that they would rather be called during an incident and have it turn
out to be nothing then to not be called when they should have been.

The facility manager notified the senior plant manager about the
situation about 11 hours after the discovery of the envelope.
Suspicious mail guidelines indicate that the postmaster should be
contacted after contacting the Inspection Service and emergency
responders. According to a USPS official, the basic intent of this
instruction is to contact the next level of management, which for the
Greenville airmail facility would be the senior plant manager.

The facility manager did not call local emergency responders until more
than 12 hours after discovery. According to suspicious mail guidelines,
such contact is to be made after contacting the Inspection Service. The
facility manager did contact the local emergency responders after
speaking with the Inspection Service, based on the advice of the
inspector he spoke with. According to the facility manager, he did not
call emergency responders earlier because he determined that the
envelope was not an immediate threat to employees, since it was not
leaking, and he was waiting to speak to the Inspection Service.

Communications with Employees and Unions Were Generally in Accordance
with Existing Guidance:

Actions by Greenville postal management and USPS headquarters to
communicate with employees and unions regarding the incident were
generally in accordance with guidance in place at the time. The
facility manager told us that, after the envelope was removed from the
facility on October 15, he and the supervisor informed employees of the
situation as they reported to work. He explained that the information
they provided included what was written on the suspicious envelope and
that the envelope had been taken to the state health department to be
tested. According to the manager, he gave employees, including union
representatives working at the facility, all the information that was
available for him to provide.[Footnote 20] Also, USPS provided talks
and news releases to employees and notified local unions on October 22,
after the results of CDC's testing were available and after
coordinating with CDC and the other involved federal and state
agencies. These communication efforts were generally in accordance with
recommendations in the suspicious mail guidance to keep employees and
their representatives informed.

However, according to officials from one union representing employees
at the facility, the Postal Service did not provide any formal
communication to local postal unions in the Greenville area about the
incident until October 22, 7 days after the discovery of the
envelope.[Footnote 21] Union officials told us that, prior to the
testing results being presented by the Postal Service, rumors were
circulating among employees about the incident. Some Greenville
employees first learned about the test results from the media rather
than USPS and, according to the facility manager, some of the
information in these media reports was not accurate. The manager
explained that he was told not to release any information on the
situation until it had been approved by headquarters. He also explained
that he could have kept employees better informed and prevented
concerns if he had received information on the testing of the substance
earlier.

In addition, according to the manager, sometime between October 15 and
21, he found information about ricin on CDC's website, printed copies
of this information, and made them available to employees and union
representatives. He also told us that he shared this information
verbally with employees. However, headquarters officials told us that
they do not want facility managers to provide health-related
information to employees and that such information should be provided
by a health professional. CDC officials have told us that, considering
the volume of incidents nationwide that lead to testing of suspicious
mail pieces, particularly those involving unknown powders, they believe
it is best to wait until the presence of a biological or chemical agent
is confirmed to provide information to employees on symptoms of
exposure.

USPS Has Made a Number of Improvements in its Suspicious Mail Guidance,
but Some Key Elements Are Lacking:

Since the ricin incident in Greenville in October 2003, USPS has made a
number of changes in its guidance on identifying and initially
responding to suspicious mail that have improved its clarity and
consistency, therefore addressing some issues raised by the incident.
These improvements will enhance its ability to manage risks posed by
potential biological and chemical threats in the mail. However, some
key elements are lacking. Without these elements in its guidance, some
issues that impaired the response to the Greenville incident could
impair responses to future incidents. In particular, the Postal Service
has not provided guidance for employees on actions to take if a mail
piece has characteristics of both suspicious mail and mail containing
hazardous material, or training for managers and supervisors on
suspicious mail that presents all the guidance they may need to make
appropriate decisions. The lack of these types of guidance could limit
the ability of postal personnel to decide whether a mail piece is
suspicious and whether initial response actions, such as shutting down
equipment and calling postal inspectors, are warranted. In addition,
the Postal Service has not provided explicit guidance on communicating
with employees and unions regarding suspicious mail incidents. Without
this type of guidance in place, employees and unions may not receive
timely information regarding mail suspected of containing a biological
or chemical agent that is sent for testing.

USPS Has Made Improvements in its Guidance on Identifying and
Responding to Suspicious Mail:

According to headquarters postal officials, the ricin incident
illustrated the need to ensure that all postal employees have the same
understanding of steps to follow for identifying and responding to
suspicious mail. Officials have emphasized that their suspicious mail
guidance has evolved since 2001 and acknowledged that different types
and versions of guidance issued over time contained inconsistencies
that could be confusing. Following the incident, USPS officials have
sought to clarify the process for identifying and responding to
suspicious mail and raise employee awareness of this process by
developing and issuing new simpler and standardized guidance. (See
table 4.) Main goals of these efforts include avoiding or minimizing
employee exposure and rapidly assessing risk.

In November 2003, USPS issued new guidelines for postal employees on
characteristics to look for in identifying suspicious mail, using an
easy to remember acronym--SLAP. This guidance categorizes indicators
into the following four categories:

* unusual Shape, such as an uneven or lopsided package,

* unusual Look and odor or sound, such as powder on the package or a
ticking sound,

* unusual Address features, such as no return address or suspicious or
threatening language on the outside of the mail piece, and:

* unusual Packaging, such as excessive tape or string.

Table 4: Key USPS Guidance on Identifying and Responding to Suspicious
Mail Developed or Issued After October 2003 Incident:

Type of guidance: Guidance documents[A]: Postal bulletin on handling
suspicious mail pieces;
Intended audience: Guidance documents[A]: Managers and supervisors;
Date issued: October 2003;
Description: Cites the ricin incident and emphasizes key steps for
responding to a suspicious mail piece. States that the suspicious
powder exercise can be applied to many suspicious mail incidents.

Type of guidance: Guidance documents[A]: "SLAP" guidance on identifying
suspicious mail;
Intended audience: Guidance documents[A]: Managers and supervisors;
Date issued: November 2003;
Description: Presents characteristics of suspicious mail in four "easy
to remember" categories, based on the acronym SLAP: unusual Shape,
Look, Address features, or Packaging.

Type of guidance: Guidance documents[A]: "Three Ps" guidance on
responding to suspicious mail;
Intended audience: Guidance documents[A]: Managers and supervisors;
Date issued: October 2003;
Description: Presents "three simple steps" for responding to a
suspicious package:
* Package - don't handle it. Isolate the area;
* People - evacuate the area around the package and notify your
supervisor;
* Plan - contact the Inspection Service, police and community first
responders.

Type of guidance: Guidance documents[A]: Suspicious mail poster;
Intended audience: Guidance documents[A]: All employees;
Date issued: February 2004;
Description: Presents the October 2003 Three Ps guidance in a poster
for USPS employees.

Type of guidance: Guidance documents[A]: Response Checklist;
Intended audience: Guidance documents[A]: Managers and supervisors;
Date issued: USPS plans to issue in late July 2005;
Description: Presents a checklist of actions to take in response to
suspicious mail and unknown powders or substances.[B].

Type of guidance: Guidance documents[A]: Poster on immediate response
actions;
Intended audience: Guidance documents[A]: All employees;
Date issued: USPS plans to issue in early August 2005;
Description: Presents the Three Ps guidance as well as more detailed
instructions for employees, supervisors, and managers on initial
actions to take in response to suspicious mail and unknown powders or
substances.[B].

Type of guidance: Training: Suspicious powder tabletop exercise;
Intended audience: Guidance documents[A]: Managers, supervisors, and
support staff;
Date issued: September 2004;
Description: Updated version of 2003 training. Discusses actions to
take in incidents involving a suspicious powder leaking from a mail
piece. Consists of a series of scenarios portraying phases of a
hypothetical incident and active exercises in responding to these
scenarios.

Type of guidance: Training: Mandatory talks on handling suspicious mail;
Intended audience: Guidance documents[A]: All employees;
Date issued: November 2003;
Description: Monthly mandatory talks delivered by managers and
supervisors to postal employees nationally. Focuses on the use of SLAP
and the Three Ps, respectively, for identifying and responding to
suspicious mail.

Source: GAO analysis of USPS suspicious mail guidance.

[A] In addition, in December 2003 and December 2004, USPS issued
updated versions of its guidelines for responding to an anthrax release
that it originally issued in November 2001. These guidelines cover a
range of response activities--including sampling, analysis, and
decontamination--and also include guidance on the initial response to a
suspected incident.

[B] According to USPS officials, its Mail Security Task Force, which
includes representatives of employee unions and management
associations, reviewed these procedures during their development.

[End of table]

These new categories provide greater clarity about how to identify a
suspicious mail piece, in a uniform, easy to remember format. Also,
unlike some previously issued guidance, they do not involve any
determinations of the type of threat, such as a biological or chemical
threat, that a mail piece may pose. In addition, USPS added several new
characteristics for employees to look for. One such characteristic--
suspicious or threatening language on the outside of the mail piece--
may have helped the Greenville airmail facility personnel to identify
the envelope in the ricin incident as suspicious mail. (Previously,
threatening language had only been cited in the decision tree
guidelines, which were aimed at managers and supervisors.) USPS
headquarters officials have emphasized that they want to make the
initial decision about whether a mail piece is suspicious as simple as
possible and that postal employees and managers generally have much
experience to draw on, in addition to the SLAP indicators, in making
these determinations.

USPS has also produced new simplified guidance on responding once a
mail piece has been identified as suspicious. In October 2003, USPS
issued guidance on "three simple steps" to follow with easy to remember
labels--Package, People, and Plan--referred to as the "three Ps." (See
fig. 5.) It followed up with a new poster for employees on these steps
in February 2004. This new guidance places additional emphasis, in an
easy to understand format aimed at all employees, on isolating and not
handling suspicious mail pieces, keeping employees away, and notifying
postal inspectors and emergency responders. It could help to prevent
uncertainty about appropriate initial response actions to an envelope
or package with characteristics of suspicious mail, as occurred in the
Greenville incident.

Figure 5: USPS Three Ps Poster:

[See PDF for image]

[End of figure]

Since 2003, in addition to producing new guidance for identifying and
responding to suspicious mail, USPS has made efforts to make employees
more aware of this guidance. In particular, since November 2003, it has
delivered monthly talks to employees that reiterate the "SLAP"
characteristics of suspicious mail pieces and the "Package, People, and
Plan" steps for responding. USPS has also communicated its guidelines
to employees through other means, including its internal Web site and
news publications. Finally, it has updated its suspicious powder
tabletop exercise to include new instructions to consult with postal
inspectors prior to evacuating the facility or contacting emergency
responders, unless an emergency exists. According to postal officials,
these efforts have been successful in making employees aware of the
appropriate actions to take in response to suspicious mail. They cited
as evidence the results of a recent survey regarding suspicious powder
incidents that the Postal Service sent to a random sample of employees.
Ninety one percent of employees who responded reported that they know
the proper steps to take when discovering a suspicious powder.[Footnote
22] In a recent review of responses to suspicious mail incidents at
selected postal facilities, the USPS Office of Inspector General found
that postal personnel were generally aware of policies for handling
suspicious mail. However, they also found that supervisors at some
facilities did not follow established guidance when managing suspicious
mail incidents.[Footnote 23]

To provide further clarification for employees on how to respond to
suspicious mail, USPS convened a working group in late 2004 to review
existing guidelines and come up with consistent, easy to understand
procedures for employees to follow. This working group developed new
procedures for response actions to take after identifying a suspicious
mail piece or an unknown powder or substance. These new procedures
include a checklist of response steps for managers and supervisors as
well as a poster for all employees. USPS plans to distribute the
checklist to managers and supervisory employees in late July 2005. It
also plans to distribute the poster to all facilities and the poster in
brochure form to all employees in early August 2005.

According to postal officials, these new procedures are based on CDC
guidance on handling suspicious mail as well as other emergency
management guidance. Officials have emphasized that the approach they
have developed for responding to suspicious mail is conservative
because it calls for taking immediate actions to protect employees when
there is a suspicion that a mail piece could be harmful, but before
this is confirmed.

These new procedures clarify initial steps that should be taken upon
the discovery of a suspicious mail piece. In particular:

* They are clearly applicable to all types of suspicious mail
incidents. Some previously issued guidance appeared to apply only to
incidents involving suspicious powders or suspected anthrax releases.

* They highlight circumstances when emergency responders should be
called immediately.

* They reflect the expanded role of postal inspectors. If no clear
emergency exists but a mail piece is suspicious, inspectors should be
called and will help determine subsequent actions.

* They provide some additional guidance on initial communications with
employees and unions regarding suspicious mail incidents.

* They clearly specify other initial actions to take to protect
employees.

Unlike some earlier guidance, postal officials are considering the new
checklist and poster to be procedures representing required immediate
steps to take in response to suspicious mail and not guidelines
representing recommended steps. Also, USPS has announced that the new
procedures supercede some previous guidance, including the decision
trees.[Footnote 24]

Since early 2003, the Inspection Service has worked closely with USPS
to define an expanded role for postal inspectors in responding to
suspicious mail incidents, including incidents involving mail leaking
an unknown powder as well as non-leaking suspicious mail.[Footnote 25]
USPS procedures regarding the release of hazardous materials state that
spill and leak teams are to be called in when there are leaks from mail
pieces, and that, when they encounter an unknown substance, they should
initiate emergency procedures. These procedures call for evacuating the
facility and calling local emergency responders. However, after the
anthrax incidents in fall 2001, a large number of incidents involving
unknown powders leaking from mail pieces occurred in the postal system,
disrupting operations and placing a heavy burden on local emergency
responders. To address this problem, inspectors now are expected to
respond to incidents involving mail leaking unknown powder as well as
other types of suspicious mail incidents.

Once a suspicious mail incident is determined to be an emergency, such
as when there are fumes or employees exhibit medical symptoms, USPS
emergency procedures need to be followed. In January 2004, USPS
established the Integrated Emergency Management Plan (IEMP) as the
Postal Service's "all-hazard" comprehensive plan for responding to all
types of emergencies, including natural disasters and man-made hazards.
A major goal of the IEMP is to establish a standardized emergency
management process throughout the postal system. The IEMP provides
instruction for individual facilities to follow in response to
emergencies affecting their facility and is tailored to the risks at
each facility. It is currently being implemented at facilities with
biohazard detection systems and, for those facilities, includes
response plans for system alerts.[Footnote 26] USPS is currently
revising the IEMP to align it with guidance in DHS's National Response
Plan, including guidance on responding to biological threats.[Footnote
27] According to postal officials, the Postal Service plans to
incorporate its new suspicious mail procedures into the IEMP and
implement the plan at all USPS facilities by the end of fiscal year
2005.

The IEMP includes procedures for notifying USPS managers, postal
inspectors, and other internal and external stakeholders, including
unions and employees, when various types of emergencies occur. For
facilities with biohazard detection systems, it establishes
responsibilities of managers and safety officers at the local level for
providing initial talks to employees and for notifying local union
representatives of system alerts and subsequent positive or negative
testing results. It also establishes responsibilities of headquarters
officials for informing national union representatives of such alerts
and testing results. Also, in other cases of a suspected anthrax
release, USPS's current anthrax guidelines establish responsibilities
of facility managers for notifying employees and union representatives
of testing results and of headquarters officials for notifying national
unions of such results.

We have advocated a risk management approach as a framework to guide
decision making in federal agencies.[Footnote 28] A risk management
approach entails a continuous process of managing, through a series of
mitigating actions, the likelihood of an adverse event happening with a
negative impact. While risk management cannot eliminate risk, it can
help reduce risk by enhancing protection from known or potential
threats with a goal of providing reasonable assurance that an
organization's objectives will be achieved. In the case of the Postal
Service, risk management can help it, among other things, to protect
employees from possible threats in the mail while avoiding unnecessary
disruption of operations. Managers at different levels within an agency
can engage in risk management decision-making, although the manager of
a facility may have more constraints than a higher level manager. Such
decision-making can be adversely affected by, among other things, the
potential for human errors in judgment and the potentially poor quality
of information driving the decisions.

Within the Postal Service, postal managers and supervisors at
facilities play a key role in making an initial assessment of the risks
posed by a mail piece, after an employee has identified it as
suspicious. The new "SLAP" guidance on identifying suspicious mail, by
providing a consistent set of characteristics to look for, will likely
help them make these decisions. In addition, the new guidance on
initially responding to suspicious mail--including the "three Ps"
guidance, related training, and the new response checklist and poster-
-provides clearer and more consistent instructions on initial steps to
take to manage the risk posed by a suspicious mail piece, before postal
inspectors or emergency responders become involved. Similarly, the
expanded role of postal inspectors in responding to suspicious mail and
the Postal Service's efforts to develop and refine "all-hazards" plans
for responding to all types of emergencies will enhance its abilities
to manage risk posed to the mail system by biological and chemical
agents.

Some Key Elements in USPS Suspicious Mail Guidance Are Lacking:

Although USPS's new guidance on identifying and responding to
suspicious mail is clearer and more consistent than the guidance it had
in place in October 2003, current guidance does not fully address
issues raised by the incident because some key elements are lacking.
Specifically, the Postal Service has not provided guidance for
employees on response actions to take if a mail piece has
characteristics of both suspicious mail and mail containing hazardous
material, and the training for managers and supervisors on suspicious
mail does not provide all the guidance they may need to make
appropriate decisions. Without these elements in its guidance, postal
personnel may have difficulty, in some cases, in deciding whether a
mail piece is suspicious and whether initial response actions, which
can disrupt postal operations, are warranted. Furthermore, the Postal
Service has not provided explicit guidance on communicating with
employees and unions regarding suspicious mail incidents, including
guidance on when information should be provided and to whom and what
types of information should be shared. Without such guidance, employees
and unions may not receive timely information regarding suspicious mail
that is sent for testing and may not feel confident that they have been
adequately informed.

USPS lacks guidance on what response actions to take in the event a
mail piece has characteristics of both suspicious mail and mail
containing hazardous material. The signs employees are trained to look
for to identify these types of mail can overlap. For example, a warning
label, one characteristic of mail containing or that may contain
hazardous material, in some cases could be considered to be a
restrictive marking or a suspicious or threatening message, both
characteristics of suspicious mail. The message on the envelope in the
Greenville incident (Caution: RICIN POISON. Enclosed in sealed
container. Do not open without proper protection.) could be considered
to have all of these characteristics. However, neither the current
procedures and training on handling mail containing hazardous material
nor the procedures and training on suspicious mail clarify what
employees should do in such cases.[Footnote 29] Furthermore, while the
hazardous material handling procedures in place in October 2003 did
indicate that supervisors should request further assistance from the
Inspection Service, if necessary after discovering an improperly
labeled mail piece suspected of containing hazardous material, the
current version of these procedures do not mention calling the
Inspection Service in these instances. Notifying the Inspection Service
is a key step in the procedures for responding to suspicious mail.

The manager of the office that produces the hazardous material handling
procedures and training told us that his office has preferred to focus
on the routine handling of mail containing hazardous materials to avoid
causing undue concern to employees about this type of mail. However,
without clear guidance in these procedures and training that employees
should follow suspicious mail procedures when a mail piece has
characteristics of both mail containing hazardous material and
suspicious mail, employees may be uncertain what to do and their
ability to initially assess the risks posed by a mail piece may be
impaired. As a consequence, their response actions taken may lack the
precautions that are in the suspicious mail procedures. By not taking
such precautions, including not handling the mail piece and calling
postal inspectors to conduct a threat assessment, employees could
unintentionally be exposed to a biological or chemical threat agent if
a mail piece did contain one.

USPS training for managers and supervisors on suspicious mail does not
provide them with all the guidance they may need to make appropriate
decisions. Managers and supervisors at postal facilities play a key
role in judging whether a mail piece is suspicious, after an employee
has initially identified it as such, and whether the situation warrants
taking the response actions outlined in the new USPS procedures. Such
actions can significantly disrupt operations through shutdowns of part
or all of a facility. Postal officials have emphasized that they have
tried to make this decision process as simple as possible and that
postal personnel are experienced in identifying suspicious mail.
However, they acknowledge that leaking powder is the most obvious
indicator of suspicious mail and that, in the absence of leaking
powder, decisions about whether a mail piece is suspicious must be
based on other characteristics and can be more difficult to make. While
USPS's new guidance on identifying and responding to suspicious mail
does apply to scenarios in which a mail piece is leaking as well as to
those in which it is not leaking, the training that USPS provides to
managers and supervisors on dealing with suspicious mail--the
suspicious powder tabletop exercise--does not cover scenarios in which
a mail piece is suspicious but not leaking a powder. Suspicious powder
incidents have posed a significant challenge to the Postal Service and
the purpose of this training has been to ensure a consistent and
protective response to these incidents while reducing unnecessary
disruption of operations. The suspicious powder tabletop exercise lasts
about one hour and USPS required managers and supervisors at facilities
with more than 50 staff to complete it in 2003 and again in 2004.

While suspicious powder incidents have comprised the majority of
suspicious mail incidents in the last several years, mail that is not
leaking but that has other suspicious mail characteristics could also
pose a biological threat. According to guidance for local responders
issued by the FBI and DHS in November 2004, a "letter/container with a
threat but no visible powder or substances present" could have "trace
amounts of material present that could represent a health
risk."[Footnote 30] CDC officials told us that, while visible leakage
of a powder from a mail piece is a very important factor in determining
whether immediate response actions are warranted, a threatening message
is also important.[Footnote 31]

In scenarios in which a mail piece may have one or more characteristics
of suspicious mail but does not appear to be leaking a powder, it may
be difficult for managers to determine if the mail piece is suspicious
and if they should disrupt operations and call the Inspection Service.
For example, some of the SLAP characteristics of suspicious mail--such
as no return address and excessive postage or tape--may not, by
themselves or in combination, indicate potential danger. Also, it may
be difficult to determine if a message on the outside of an envelope is
suspicious or threatening--another characteristic of suspicious mail--
as occurred in the Greenville incident. Judgments about whether a mail
piece is indeed suspicious require managers and supervisors to make an
initial assessment of the risk posed by a mail piece. In the Greenville
incident, the manager decided to end the facility evacuation and to
postpone further action until the morning based to a large extent on
the fact that the envelope was not leaking. In situations in which a
mail piece poses a potential biological threat, whether it is leaking
or not, a quick response is important. According to CDC officials,
since it is not clear what is inside of a suspicious mail piece, the
earlier that response actions are taken, the better.

Finally, although the new poster on responding to suspicious mail
indicates that calling the Inspection Service is one of the immediate
response actions that should be taken, USPS's suspicious powder
training exercise for managers and supervisors does not provide
instructions on how soon inspectors should be called after the
discovery of a non-leaking suspicious mail piece. As occurred in the
Greenville incident, without training that reinforces other guidance
about when to call inspectors, managers may wait to call them when in
doubt about whether a mail piece is suspicious. Furthermore, in some
areas, including Greenville and Charlotte, callers to the Inspection
Service after regular business hours are directed to dial a number for
live assistance in the event of an emergency. Facility managers may
hesitate to do so if there is not clear evidence of an
emergency.[Footnote 32] According to postal officials, most mail
processing is done from 4:00 p.m. to 8:00 a.m.

USPS lacks explicit guidance on communicating with employees and unions
regarding suspicious mail incidents. Other than procedures related to
biohazard detection system alerts and other cases of suspected anthrax
releases, USPS lacks detailed guidance on communicating with employees
and unions regarding suspicious mail incidents, including guidance on
when information should be provided and to whom and what types of
information should be shared. The Postal Service's draft of its new
procedures for responding to suspicious mail which it originally
provided to us did not contain guidance on communications with
employees and unions. The Postal Service added some guidance on this
topic to these procedures after we discussed with them our preliminary
findings that it had limited guidance in this area.[Footnote 33] The
new procedures state that supervisors and managers should communicate
with employees and local unions about suspicious mail incidents as soon
as possible. It also states that information provided "must be limited
to known facts," to avoid disseminating unintended misinformation, and
that local emergency responders can assist in providing information.
While this guidance provides some additional instructions about initial
communications, it does not specify how local union organizations
should be notified, what types of information should be provided, or
whether or when information should be provided after the initial
occurrence of the incident, in cases in which mail pieces are sent for
testing. Previous guidance, in an e-mail message accompanying the March
2003 decision trees, discussed the need to keep employees and unions
informed "at all stages, including the final results and resolution of
the incident." However, this guidance has been replaced by the new
procedures.

Although Postal Service personnel made a number of efforts to provide
information to employees and unions about the October 2003 incident,
some issues did arise concerning the timing and method of local union
notifications and whether the facility manager should have provided
information on symptoms of ricin exposure to facility employees.
Furthermore, the lack of formal communications and status updates for
employees during the 7 day period from the discovery of the envelope
until the results of the testing were shared may have led to rumors and
employee concerns. Finally, in our related review of the November 2003
incident in which an envelope containing a substance initially
suspected of being ricin was discovered at a White House mail
processing facility, we have identified issues related to the Postal
Service's subsequent communication of information regarding this
incident to employees and unions. We plan to report separately on this
incident later this year. The Postal Service's new procedures for
responding to suspicious mail do provide some additional guidance on
initially communicating with employees and unions that may help to
avoid some of these issues from arising in future incidents. However,
these procedures do not provide explicit instructions that could help
to avoid all of these types of issues, particularly in cases where a
suspicious mail piece is sent for testing.

According to Inspection Service officials, once inspectors have been
alerted about a suspicious mail piece, they often can determine that
the item poses no risk through their initial threat assessment, which
includes checking the package or envelope or leaking substance and
contacting the mailer or addressee. In instances in which, after an
initial threat assessment, mail is suspected of containing a biological
or chemical agent or other hazardous substance or has a threatening
message, such mail pieces are sent for testing to a state or local
laboratory and possibly also to CDC.[Footnote 34] A series of tests may
be performed to determine whether a threat agent is present. As
demonstrated in the Greenville incident, it could take a number of days
for testing results to become available. In such instances, employees
and unions may become concerned if they are not kept informed on what
has transpired and on the status of the testing.

The General Services Administration has issued guidelines for managing
biological threats in federal mail facilities that emphasize the
importance of communications with local union officials and employees
in the event that a threat appears credible.[Footnote 35] Specifically,
these guidelines state that all information relevant to such threats
should be provided as quickly as possible, preferably without waiting
for a request.[Footnote 36] While these guidelines are intended for use
by mail centers located in federal agencies, in our view, their
recommendations regarding communications with employees and unions are
relevant to the Postal Service. In addition, risk communication experts
have emphasized that risk information should be accurate and clear and
provided in a timely fashion to prevent unofficial sources, such as the
media, from reporting information before official sources.[Footnote 37]

In a previous report on communications issues related to the anthrax
incidents, we identified the need for more explicit guidance on
communicating facility sampling results to employees as a lessons
learned to avoid concerns and maintain trust and credibility.[Footnote
38] We have also previously reported on the need to provide complete
and timely health-related information to postal workers to maintain
trust and credibility and to help ensure that workers have essential
information for making informed health decisions.[Footnote 39] Without
specific guidance on communications with employees and unions regarding
incidents in which a suspicious mail piece is sent for testing,
communications issues may arise in future incidents. Such guidance can
clarify the responsibilities of managers at different levels for
providing information to employees and unions regarding suspicious mail
incidents and help to avoid situations in which efforts by management
to communicate information do not meet expectations.

Conclusions:

Improvements made by the Postal Service in its suspicious mail guidance
since the October 2003 incident should help postal personnel determine
whether mail is suspicious and should also help make them more aware of
initial actions to take upon identifying suspicious mail. As a
consequence, these improvements should enhance the ability of the
Postal Service to manage risks posed by potential biological and
chemical threats in the mail. However, the lack of additional guidance
in some areas could limit the ability of postal personnel to make
appropriate decisions in responding to future incidents involving mail
that may contain biological or chemical agents. In particular, without
guidance on actions to take in cases where a mail piece has
characteristics of both mail containing hazardous material and
suspicious mail, employees may follow the procedures for mail
containing hazardous material, which do not recommend some precautions
in the suspicious mail guidance, such as not handling the mail piece.
Furthermore, without training on handling suspicious mail incidents
that covers different types of scenarios and how soon inspectors should
be called, managers and supervisors may not have all the guidance they
need to decide whether a mail piece is suspicious and initial response
actions are warranted, and they may delay calling postal inspectors. If
a mail piece actually contained a biological or chemical agent, not
following the steps in the suspicious mail guidance could result in
employees being exposed to the agent.

Finally, the lack of explicit guidance on communicating with employees
and unions regarding incidents in which a suspicious mail piece is sent
for testing could lead to situations in which employees and unions
believe that they have not been adequately informed. Such situations
can affect the Postal Service's ability to maintain trust and
credibility with employees and unions. In particular, explicit guidance
on when information should be provided and to whom and what types of
information should be shared would clarify the responsibilities of
managers at different levels for providing information and help to
avoid concerns by employees and unions.

Recommendations for Executive Action:

To help prepare postal personnel to respond to future incidents
involving mail that may contain biological or chemical agents, we
recommend that the Postmaster General implement the following three
recommendations.

* The Postal Service should provide guidance to employees on the
response actions to take in the event a mail piece has characteristics
of both suspicious mail and mail containing hazardous material.

* The Postal Service should expand its suspicious mail training for
managers and supervisors to include:

* exercises for responding to various scenarios involving suspicious
mail pieces, including scenarios in which a mail piece is suspicious
but is not leaking a powder, and:

* instructions on how soon inspectors should be called after the
discovery of a suspicious mail piece.

* The Postal Service should provide explicit guidance to managers on
communicating with employees and unions regarding incidents in which a
suspicious mail piece is sent for testing. This guidance should specify
when information should be provided and to whom and what types of
information should be shared.

Agency Comments and Our Evaluation:

We requested comments on a draft of this report from the Postal
Service, CDC, DHS, the FBI, and the two postal unions that represent
employees of the Greenville airmail facility (the American Postal
Workers Union and the National Postal Mail Handlers Union). The Postal
Service provided written comments generally agreeing with our
recommendations. These comments are reprinted in appendix II and are
summarized below. The Postal Service also provided some technical
comments, which we incorporated. The FBI provided technical comments,
which we incorporated, to clarify portions of our draft report that
described actions of its Joint Terrorism Task Force in the Greenville
area. DHS and CDC had no comments on the draft. The American Postal
Workers Union also had no comments and the National Postal Mail
Handlers Union did not accept our offer to review the draft.

The Postal Service stated in its overall comments on the draft report
that it concurs with the intent of our recommendations and, in
response, intends to implement a number of improvements in its
suspicious mail guidance, including expanded training for employees.
The Postal Service also emphasized that it does not believe such
guidance should be unduly specific or detailed. It explained that it
believes that the proper approach is to keep instructions to employees
relatively basic and general, so that they will be easily understood
and applicable to many potential situations. While we understand the
Postal Service's rationale for this approach, we also believe that it
needs to ensure that its employees have adequate guidance to be able to
make appropriate decisions in responding to future incidents involving
mail that may contain biological or chemical agents.

Regarding response actions in the event a mail piece has
characteristics of both suspicious mail and mail containing hazardous
material, the Postal Service told us that it will revise existing
guidance to clarify appropriate response actions to take in such
scenarios. Regarding its suspicious mail training for managers and
supervisors, the Postal Service stated that it will expand and improve
this training by adding exercises that include a variety of suspicious
mail scenarios, including ones involving mail pieces that are not
leaking a powder. It also noted that early contact with the Inspection
Service is specified in its new response checklist and that its new
training will stress the need to contact the Inspection Service in any
suspicious mail incident. However, it does not plan to impose specific
timeframes for calling inspectors, to allow managers and supervisors
the flexibility to respond to events as they occur and evolve. While
specific timeframes may not be needed, we continue to believe that
training for managers and supervisors should reinforce the message in
the Postal Service's new guidance that calling the Inspection Service
is one of the immediate response actions that should be taken upon the
discovery of any suspicious mail piece.

Regarding communications with employees and unions concerning incidents
in which a suspicious mail piece is sent for testing, the Postal
Service stated that it fully agrees with the concept that timely and
accurate communication with employees is vitally important, especially
when their safety and health is concerned. It intends to provide
additional guidance to local managers regarding their responsibility
for providing information, including general guidelines on the types of
events that should lead to communication with employees and unions.
While we are pleased that the Postal Service plans to provide this
additional guidance, we note that its response does not indicate
whether this guidance will address situations in which a suspicious
mail piece is sent for testing. For such situations, we continue to
believe that the Postal Service should specify when information should
be provided and to whom and what types of information should be shared.
Such explicit guidance could be provided in various ways, including
training. Such guidance can help to avoid situations in which efforts
by management to communicate information do not meet expectations.

As arranged with your office, unless you publicly announce its contents
earlier, we plan no further distribution of this report until 30 days
after its date. At that time, we will send copies of this report to
congressional committees and subcommittees with responsibility for
postal issues, the Postmaster General, CDC, DHS, the FBI, and the South
Carolina Department of Health and Environmental Control, as well as to
postal unions and other interested parties. We will provide copies to
others upon request. In addition, the report will be available at no
charge on the GAO Web site at [Hyperlink, http://www.gao.gov]
[Hyperlink, http://www.gao.gov].

If you have any questions about this report, please contact me at
[Hyperlink, siggerudk@gao.gov] or (202) 512-2834. Contact points for
our offices of Congressional Relations and Public Affairs may be found
on the last page of this report. Staff who made key contributions to
this report are listed in appendix III.

Sincerely yours,

Signed by:
Katherine A. Siggerud:
Director, Physical Infrastructure Issues:

[End of section]

Appendixes:

Appendix I: Scope and Methodology:

To determine what actions the United States Postal Service (USPS), the
Centers for Disease Control and Prevention (CDC) and other agencies
took in responding to the October 2003 incident in Greenville, South
Carolina, to protect the health of postal employees and the public, we
reviewed documents of agencies involved in the response, including
timelines, that explained the sequence and timing of actions the
agencies took during the response. We also interviewed officials of
these agencies and of unions representing workers at the Greenville
airmail facility concerning the actions taken to protect the health of
postal employees and the public and to discuss reasons for any delays
in taking these actions. We obtained pertinent documents and
interviewed officials from the following organizations:

* United States Postal Service (USPS) headquarters and Greater South
Carolina Area.

* United States Postal Inspection Service (Inspection Service)
headquarters and Charlotte, North Carolina office.

* Centers for Disease Control and Prevention (CDC).

* Department of Homeland Security (DHS).

* Federal Bureau of Investigation (FBI) headquarters and Columbia,
South Carolina Division.

* South Carolina Department of Health and Environmental Control.

* American Postal Workers Union.

* National Postal Mail Handlers Union.

We developed a timeline of actions taken by the agencies based on the
information in agency documents, generally determining the actions of a
specific agency from the timeline provided by that agency, and
corroborated, to the extent possible, the timeline with information
gained from interviews with agency officials.

To determine what USPS guidance for identifying and responding to
suspicious mail was in place in October 2003 and to what extent actions
taken by USPS personnel were in accordance with this guidance, we
reviewed USPS guidance available in October 2003 for identifying and
initially responding to suspicious mail, analyzed this guidance for
clarity and consistency, and compared actions taken by USPS personnel
with steps in this guidance. In performing this analysis, we also
reviewed related USPS procedures and guidance for identifying, handling
and responding to hazardous materials in the mail and USPS guidance on
actions to take during emergencies. We also reviewed USPS guidance on
communicating with employees and unions that could pertain to
suspicious mail incidents and compared USPS's actions to communicate
with employees and unions with its existing guidance on such
communication. We also interviewed local and national officials from
USPS and postal unions about suspicious mail and other related
guidance, actions taken during the response, and communication with
employees and the unions about the incident. We used information from
the interviews to further understand and clarify USPS guidance and
actions taken during the response.

To determine what changes USPS has made in its guidance since the
incident and to what extent current USPS guidance addresses issues
raised by the incident, we reviewed current USPS guidance related to
suspicious mail and communicating with employees and the unions about
suspicious mail incidents, and compared it to guidance available during
the incident to identify changes and the extent to which improvements
have been made that address issues raised by the incident. To assist in
evaluating USPS suspicious mail guidance, we also reviewed guidance
developed by CDC, DHS, the General Services Administration and others
on mail security and responding to biological threats in the mail and
reports of the USPS Office of the Inspector General related to
suspicious mail. We reviewed previous GAO work on risk management and
risk communication, as well as some other pertinent literature, and
compared this information with USPS guidance to determine whether they
incorporated a risk management or risk communication approach in their
guidance. We also reviewed previous GAO work on USPS's response to
anthrax to obtain a broader perspective on how USPS has responded to
risks posed by biological threats in the mail system. In addition, we
interviewed USPS officials concerning how USPS's suspicious mail
guidance was developed, plans for updating or revising current guidance
and developing new guidance, and how USPS used risk management in the
development of its guidance. We also interviewed officials from the
American Postal Workers Union and the National Postal Mail Handlers
Union about USPS communication with employees and unions during
suspicious mail incidents. Finally, we reviewed scientific literature
on ricin and interviewed experts in CDC and the U.S. Army Medical
Research Institute of Infectious Diseases to determine the potential
health risks associated with ricin or other biological or chemical
agents in the mail system.

We limited the suspicious mail guidance we reviewed to those pertaining
to the initial discovery of a suspicious mail piece until the point
when the mail piece is removed from the facility. We also limited the
comparison of actions USPS took with suspicious mail guidance to
actions taken from the initial discovery through the removal of the
envelope from the facility, except for communication with employees and
unions, which we covered until final results of testing of the envelope
and its contents were available. We did not review the Postal Service's
implementation of its biohazard detection systems or related
procedures, other than aspects of these procedures that pertained to
communications with employees and unions. We did not review the
communication among all involved agencies or with emergency responders
or the public. We also did not review the procedures of other agencies
or of the Inspection Service. Finally, we did not review the capability
of the Inspection Service or other agencies to conduct initial threat
assessments or actions relating to the investigation of this incident.

We performed our work from June 2004 through May 2005 in Washington,
D.C; Greenville, South Carolina; Columbia, South Carolina; Charlotte,
North Carolina; and Atlanta, Georgia. We conducted our review in
accordance with generally accepted government auditing standards.

[End of section]

Appendix II: Comments from the U.S. Postal Service:

Thomas G. Day:
Senior Vice President, Government Relations:
United States Postal Service:

June 28, 2005:

Ms. Katherine A. Siggerud:
Director, Physical Infrastructure Issues:
United States Government:
Accountability Office Washington, DC 20548- 0001:

Dear Ms. Siggerud:

Thank you for providing U.S. Postal Service with the opportunity to
review and comment on your draft report, U.S. Postal Service: Guidance
on Suspicious Mail Needs Further Refinement.

We concur with the intent of the report's recommendations. As you are
aware, the Postal Service continuously strives to refine and strengthen
our responsive actions regarding any mail which is suspected of having
the potential to cause harm to our employees or others, and we
therefore appreciate any suggestions concerning improvements we can
make to our guidance and training to our employees in this regard. We
also fully agree with the concept embodied in your recommendations that
timely and accurate communication with our employees is vitally
important, especially when their safety and health are concerned.

However, to the extent the recommendations can be read to require the
Postal Service to issue guidance which is unduly specific or detailed,
the Postal Service disagrees with that approach. In formulating our
practices and policies for responding to "suspicious mail" and the
guidance and training related thereto, we have remained mindful of the
multitude of potential events and permutations of those events which
our employees may face. Keeping all of the potential variations in
mind, it is simply not possible to design a detailed set of specific,
hard and fast rules that will help our employees to respond to all
potential situations and also give them the flexibility necessary to
react to events as they occur and evolve. We have therefore been
careful not to design any response plans that are too specific and
inflexible.

Instead, we have tried to keep our instructions to our employees
relatively basic and general, so that they will be easily understood by
our employees and widely applicable to the many potential situations
they may face. We instruct employees to evaluate four characteristics
of an individual item of mail to determine if it is suspicious - Shape,
Look, Address and Packaging. If a mail item is judged to be suspicious
based upon these characteristics, then we have chosen to implement a
simplified and easily understood set of guidelines that emphasizes the
safety of our employees and reliance upon the expertise of Postal
Inspectors and local first responders. If a suspicious item of mail is
identified, employees have been instructed to follow three simple
steps: (1) Don't handle. Isolate it; (2) Clear the area of people,
notify supervisor; and, (3) Contact the Inspection Service and follow
your facility emergency plan. We continue to believe that this is the
proper approach.

That being said, the following paragraphs provide the current status
and planned approach for addressing each of the report's
recommendations:

Recommendation 1:

The Postal Service should provide guidance to employees on the response
actions to take in the event a mail piece has characteristics of both
suspicious mail and mail containing hazardous material.

We concur with this recommendation. The Postal Service will continue to
work to refine and clarify response actions associated with suspicious
mail and mail containing hazardous materials, and we will emphasize the
appropriate response actions to take with regard to mail containing
characteristics of both suspicious and hazardous mail in all planned
revisions to existing guidance. We want to keep our employees safe and
to insure that they know how to respond to any suspicious mail scenario.

Recommendation 2:

The Postal Service should expand its suspicious mail training for
managers and supervisors to include:

Exercises for responding to various scenarios involving suspicious mail
pieces, including scenarios in which a mail piece is suspicious but is
not leaking a powder and:

Instructions on how soon inspectors should be called after the
discovery of a suspicious mail piece.

We concur with your recommendation concerning our training exercises,
and will expand and improve our training by utilizing exercises that
include a variety of suspicious mail scenarios, including ones
involving mail items that are not leaking powder. Again, our primary
interest is to keep our employees safe. Training that we are developing
which will include a greater variety of suspicious mail scenarios will
include: (1) a web-based training that we are developing which will be
completed by the end of this fiscal year and that will be delivered to
both supervisors/managers and craft employees beginning in the fall of
2005; (2) a supplemental paper-based program that will be issued by
Emergency Preparedness in conjunction with Employee Resources and
Development; and, (3) a video that is being developed by the Inspection
Service that will be included with the paper-based program.

Further, we will modify the current tabletop exercises on suspicious
mail to incorporate additional suspicious mail situations, including
ones involving mail items that are not leaking powder. The current
tabletop exercises are slated to be revamped so that we can deliver
them in the fall of 2005.

With regard to the recommendation concerning the timeframe for
contacting the Inspection Service, as we noted above, early contact
with the Inspection Service so that we can rely on their expertise is
an important component of the guidance we provide to our employees for
responding to suspicious mail. Indeed, this component is specifically
addressed in the checklist that is being sent to all Executive and
Administrative Schedule (EAS) employees at their homes. Additionally,
we will also insure that all of the training noted above will likewise
stress the need to contact the Inspection Service in any suspicious
mail incident.

However, to the extent this recommendation seeks to impose a specific,
inflexible time frame in which to call the Inspection Service after the
discovery of a suspicious mail item, it is not consistent with the
philosophy of our guidance. As noted above, our guidance is designed to
allow our supervisors and managers the flexibility to respond to
individual and fact-specific events that they are confronting as those
events occur and evolve.

Recommendation 3:

The Postal Service should provide explicit guidance to managers on
communicating with employees and unions regarding incidents in which a
suspicious mail piece is sent for testing. This guidance should specify
when information should be provided and to whom and what types of
information should be shared.

As noted above, the Postal Service agrees that timely and accurate
communication with our employees is vitally important, especially when
their safety and health is concerned. However, to the extent the
recommendations can be read to require the Postal Service to issue
guidance which is unduly specific or detailed, the Postal Service
disagrees with that approach for the reasons noted above. The Postal
Service will provide additional guidance to ensure that local
management understands its responsibility for providing information to
employees. While we do not believe that establishing a specific set of
circumstances that determine how and when communication with employees
is required, we will provide general guidelines concerning the type of
events that should lead to communication with employees and the unions
that represent them.

If you or your staff wishes to discuss any of these comments further, I
am available at your convenience.

Sincerely,

Signed by:
Thomas G. Day:

[End of section]

Appendix III: Contact and Staff Acknowledgments:

Contact:

Katherine Siggerud, (202) 512-2834 or [Hyperlink, siggerudk@gao.gov]

Staff Acknowledgments:

In addition to the above, Susan Fleming, Assistant Director; Heather
Balent; Colin Fallon; Scott Farrow; Judy Guilliams-Tapia; Daniel
Kaneshiro; Jamie Meuwissen, and Matthew Mohning made key contributions
to this report.

[End of section]

Related GAO Products:

Anthrax Detection: Agencies Need to Validate Sampling Activities in
Order to Increase Confidence in Negative Results. [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-05-251] Washington, D.C.: March
31, 2005.

21st Century Challenges: Reexamining the Base of the Federal
Government. [Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-325SP] Washington, D.C.: February 2005.

High-Risk Series: An Update. [Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-207] Washington, D.C.: January 2005.

U.S. Postal Service: Better Guidance Is Needed to Ensure an Appropriate
Response to Anthrax Contamination. [Hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-04-239] Washington, D.C.: September 9, 2004.

U.S. Postal Service: Clear Communication with Employees Needed Before
Reopening the Brentwood Facility. [Hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-04-205T] Washington, D.C.: October 23, 2003.

Bioterrorism: Public Health Response to Anthrax Incidents of 2001.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-152] Washington,
D.C.: October 15, 2003.

Capitol Hill Anthrax Incident: EPA's Cleanup Was Successful;
Opportunities Exist to Enhance Contract Oversight. [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-03-686] Washington, D.C.: June 4,
2003.

U.S. Postal Service: Issues Associated with Anthrax Testing at the
Wallingford Facility. [Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
03-787T] Washington, D.C.: May 19, 2003.

U.S. Postal Service: Better Guidance is Needed to Improve Communication
Should Anthrax Contamination Occur in the Future. [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-03-316] Washington, D.C.: April
7, 2003.

Major Management Challenges and Program Risks: U.S. Postal Service.
[Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-03-118] Washington,
D.C.: January 2003.

Diffuse Security Threats: USPS Air Filtration Systems Need More Testing
and Cost Benefit Analysis Before Implementation. [Hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-02-838] Washington, D.C.: August
22, 2002.

U.S. Postal Service: Moving Forward on Financial and Transformation
Challenges. [Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-02- 694T]
Washington, D.C.: May 13, 2002.

Highlights of GAO's Conference on Options to Enhance Mail Security and
Postal Operations. [Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-02-
315SP] Washington, D.C.: December 20, 2001.

Homeland Security: A Risk Management Approach Can Guide Preparedness
Efforts. [Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-02-208T]
Washington, D.C.: October 31, 2001.

Combating Terrorism: Observations on Biological Terrorism and Public
Health Initiatives. [Hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO/T-
NSIAD-99-112] Washington, D.C.: March 16, 1999.

(543103):

FOOTNOTES

[1] We have issued a number of reports on the response to these
incidents. See, for example, GAO,U.S. Postal Service: Better Guidance
Is Needed to Ensure an Appropriate Response to Anthrax Contamination,
GAO-04-239 (Washington, D.C.: Sept. 9, 2004); U.S. Postal Service:
Better Guidance Is Needed to Improve Communication Should Anthrax
Contamination Occur in the Future, GAO-03-316 (Washington, D.C.: Apr.
7, 2003); and Bioterrorism: Public Health Response to Anthrax Incidents
of 2001, GAO-04-152 (Washington, D.C.: Oct. 15, 2003).

[2] Biological agents are microorganisms capable of causing disease or
toxins derived from a living organism. Chemical agents are poisonous
vapors, aerosols, liquids, or solids that have toxic effects.

[3] In addition, in February 2004, a powder identified as ricin was
discovered in a Senate office building mailroom.

[4] Ricin is considered to be a biological agent because it is derived
from a plant, but also a chemical agent because it is a toxin that
causes cell death and symptoms similar to those caused by chemical
agents. Ricin appears on CDC's select agent list. CDC worked with
representatives of several countries, U.S. intelligence officials, and
safety professionals to establish this list of 42 viruses, bacteria,
toxins, and other agents considered to have the potential to pose a
severe threat to public health and safety.

[5] GAO has designated risk management as an emerging challenge for the
federal government. See GAO, High-Risk Series: An Update, GAO-05-207
(Washington, D.C.: January 2005) and 21ST Century Challenges:
Reexamining the Base of the Federal Government, GAO-05-325SP
(Washington, D.C.: February 2005).

[6] Biohazard detection systems are automated detection systems that
analyze air samples collected as mail moves through processing machines.

[7] Joint terrorism task forces, under the leadership of the FBI, are
comprised of local, state, and federal officers and agents, and are
responsible for responding to suspected acts of terrorism.

[8] USPS safety officers are responsible for monitoring and assessing
safety hazards and potentially unsafe conditions, among other things.

[9] According to FBI officials, they were notified about the envelope
by the U.S. Coast Guard's National Response Center. This center has
agreements with various federal entities to make notifications
regarding incidents meeting established criteria.

[10] The letter made reference to an April 2003 Department of
Transportation regulation that increased the required number of hours
that commercial truck drivers had to rest in between shifts from 8 to
10 hours, starting in January 2004. (68 Fed. Reg. 22456, Apr. 28, 2003)

[11] The Laboratory Response Network is a national network of labs
coordinated by CDC to respond to biological and chemical terrorism and
other public health emergencies.

[12] The FBI, with assistance from the Inspection Service and South
Carolina law enforcement, conducted the investigation of this incident.
This investigation was outside the scope of our review. According to
the FBI, this investigation is still ongoing.

[13] The version in the April 2003 training exercise was titled
"Decision Trees for Anthrax-related Emergencies."

[14] A hazardous material is any article or substance designated by the
U.S. Department of Transportation as being capable of posing a risk to
health, safety, and property during transportation. Most hazardous
materials are nonmailable. However, USPS does accept for mailing some
specified hazardous materials, if properly packaged and labeled
according to Postal Service requirements and in quantities not large
enough to present a serious hazard to safety or human health. Examples
of such materials are medical samples, pesticides and herbicides,
propane, and paint.

[15] In addition, according to postal officials, general provisions in
the Postal Service's collective bargaining agreements with employee
unions required it to provide unions with information on workplace
conditions, including information on suspicious mail incidents. These
agreements require USPS to make available to the unions all relevant
information necessary for collective bargaining or the enforcement,
administration, or interpretation of the agreements, including
information necessary to determine whether to file or continue the
processing of a grievance under the agreement. Under the agreements,
employees may file a grievance if they believe they are being required
to work under unsafe conditions, among other reasons.

[16] The Postal Service defines a piece of mail as a single addressed
article of mail. However, Postal Service officials told us that
envelopes or packages without an address that appear suspicious should
be handled according to suspicious mail guidance.

[17] USPS has links on its internal Web site to Web pages maintained by
CDC and the Occupational Safety and Health Administration that provide
information on various bioterrorism and chemical agents, including
ricin, and, according to postal headquarters officials, these links
were available to postal employees at the time of the incident.

[18] According to these procedures an outwardly hazardous material or
situation exists if a mail piece is smoking, irritating, odorous,
labeled or marked as hazardous, if the material is in a gaseous or
solid powder form and is migrating away from its container, if
defensive measures have not worked, or if the situation appears to be
getting worse. In a USPS-issued bulletin issued shortly after the
incident, on October 30, 2003, spill and leak teams are instructed to
retreat and call for outside expert assistance if they suspect or
confirm an emergency.

[19] In addition, at the time of the incident, one of the three people
responding as the spill and leak team did not have the required
training to be part of this team. The supervisor explained that, at the
time, he thought that the employee had received the required training.

[20] He noted that he could not provide some details because he had
been instructed not to do so due to the investigation of the incident.

[21] According to these union officials, USPS informed its national
office about the incident by phone the day after it occurred, on
October 16.

[22] According to postal management, these results are based on
responses to a questionnaire that was sent to the homes of a random
sampling of employees. Ten thousand employees received the
questionnaire and 2,921 responded.

[23] See USPS, Office of Inspector General, Management Advisory -
Response to Incidents Involving Suspicious Mail and Unknown Powders and
Substances, DA-MA-05-001 (Washington, D.C.: May 27, 2005). In another
recent review of a suspicious mail incident that occurred in
Washington, D.C., in August 2004, the Inspector General found that
Postal Service and Inspection Service personnel did not effectively
respond. See USPS, Office of Inspector General, Postal Service
Practices with Regard to Handling Suspicious Mail, SA-OT-05-002
(Washington, D.C.: May 20, 2005).

[24] In its recent report on the Postal Service's responses to
suspicious mail incidents, the Office of Inspector General recommended
that the Postal Service remove all outdated references on its internal
suspicious mail Web site. The Postal Service responded that it would
place the new procedures on its Web site and that it is currently
removing from the site all information and documents containing
conflicting procedures to ensure consistency of policy. See USPS,
Office of Inspector General, Management Advisory - Response to
Incidents Involving Suspicious Mail and Unknown Powders and Substances,
DA-MA-05-001.

[25] To prepare for this new role, the Inspection Service has provided
over 200 of its 1,877 inspectors with training in responding to
dangerous mail, including hazardous material releases from mail. It
plans to have these inspectors become part of dangerous mail response
teams located throughout the United States. The Inspection Service has
also established a system for reporting on suspicious mail incidents
and plans to provide inspectors with equipment that will assist in the
assessment of suspicious substances.

[26] A system alert is a signal from a biohazard detection system when
its internal test indicates the presence in the mail stream of the
bacterium that causes the disease anthrax.

[27] DHS issued the National Response Plan, a comprehensive plan for
addressing all hazards, in January 2005.

[28] The risk management approach we have advocated includes fully
linking strategic goals to plans and budgets, assessing values and
risks of various courses of action as a tool for setting priorities and
allocating resources, and using performance measures to assess
outcomes. See, for example, GAO, Homeland Security: Agency Plans,
Implementation, and Challenges Regarding the National Strategy for
Homeland Security, GAO-05-33 (Washington, D.C.: Jan. 14, 2005);
Homeland Security: Summary of Challenges Faced in Targeting Oceangoing
Cargo Containers for Inspection, GAO-04-557T (Washington, D.C.: Mar.
31, 2004); Rail Security: Some Actions Taken to Enhance Passenger and
Freight Rail Security, but Significant Challenges Remain, GAO-04-598T
(Washington, D.C.: Mar. 23, 2004); and Homeland Security: A Risk
Management Approach Can Guide Preparedness Efforts, GAO-02-208T
(Washington, D.C.: Oct. 31, 2001).

[29] In situations where a mail piece has stains, leakage, or an
unusual odor, the hazardous material handling procedures do indicate
that employees should follow USPS procedures for hazardous material
releases. These characteristics are similar to the following
characteristics for suspicious mail: powder on the package or odors,
discoloration, or oily stains. USPS's new guidance on suspicious mail
also applies to unknown powders or substances leaking from mail and the
Postal Service plans to update its hazardous material release
procedures to ensure consistency with this new guidance.

[30] FBI-DHS-HHS/CDC, Guidance on Initial Responses to a Suspicious
Letter/Container With a Potential Biological Threat (Washington, D.C.:
November 2, 2004).

[31] CDC has issued guidance on how to recognize and handle a
suspicious package or envelope. See
http://www.bt.cdc.gov/agent/anthrax/mail/suspiciouspackages.asp.

[32] According to the Inspection Service, they are considering ways to
increase the availability of inspectors by phone. For example, the
service has a national 24-hour phone number for internal reporting of
incidents within the Inspection Service and they are considering making
this phone number available to postal facilities to call when they
discover suspicious mail pieces.

[33] Postal officials have acknowledged that this new guidance on
communications was added as a result of our discussions with them.

[34] In fiscal year 2004, according to data maintained by the
Inspection Service, about 500 suspicious mail pieces or substances
discovered in U.S. Postal Service facilities were either field tested
or sent to laboratories to be tested.

[35] See General Services Administration, GSA Policy Advisory: National
Guidelines for Assessing and Managing Biological Threats in Federal
Mail Facilities (Washington, D.C.: December 29, 2003).

[36] Occupational Safety and Health Administration standards require
employers to disclose exposure-related test results to any employee who
requests these results. See 29 CFR 1910.1020 (e) (1) (i).

[37] GAO, Homeland Security: Communication Protocols and Risk
Communication Principles Can Assist in Refining the Advisory System GAO-
04-682 (Washington, D.C.: June 25, 2004).

[38] GAO-03-316.

[39] GAO, U.S. Postal Service: Issues Associated with Anthrax Testing
at the Wallingford Facility, GAO-03-787T (Washington, D.C.: May 19,
2003); and U.S. Postal Service: Clear Communication with Employees
Needed before Reopening the Brentwood Facility, GAO-04-205T
(Washington, D.C.: Oct. 23, 2003).

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