United States Department of the Interior BUREAU OF LAND MANAGEMENT Winnemucca District Of?ce 5100 East Winuemuccu Boulevard Winnemucca, Nevada 89445-292l Phone: (775) 623-1500 Fax: (775) 623-1503 TAKE Email: wfoweb@.blm.gov INAM ER In Reply Refer to: 5-01 2930 (NV020.00) CERTIFIED MAIL 7014 2870 0001 4873 0156 RETURN RECEIPT REQUESTED Charlie Dolman Event Operations Director Burning Man 2015 Event Black Rock City, LLC Special Recreation Permit 660 Alabama St San Francisco, CA 94110?2008 March 12, 2015 Dear Mr. Dolman: On January 30, 2015, I sent you a letter and the 2014 Special Recreation Permit (SRP) close-out documents. I stated in that letter ?The Bureau of Land Management (BLM) will soon be providing additional details to BRC about public safety concerns.? Enclosed with this letter is the ?Safety. Health and Security Issues of 2014 Burning Man Event? report that documents the issues and concerns we identified during the 2014 Burning Man event. I was on-site before, during, and after the Burning Man event to administer the 2014 SRP. For those two weeks, I determi nedly interacted with BLM staff and BLM Law Enforcement, as well as all cooperators and Black Rock City, LLC (BRC). Throughout the 2014 event, I saw ?rst-hand numerous successes, sound procedures, de?ciencies, and failures within both the BLM and BRC. By being the eyes, ears and boots on the ground for two weeks, I gained a better understanding and appreciation of the SRP and all facets of SRP compliance. Burning Man truly is an amazing event to plan for and implement, and it takes knowledgeable and dedicated staff, willing cooperators and compliant participants effectively working together from start to ?nish to make this a safe and enjoyable experience for everyone. The BLM has previously discussed, both with BRC and cooperators, the immediate need to enhance and ensure public safety and security at the 2015 Burning Man event. Safety is essential and a priority and will require a commitment from all of us to succeed. In advance of the 2015 event, BRC and the BLM continue to have the opportunity to enhance the focus and priority on health, safety and security by making important modi?cations for this year and future years. In order to ensure the 2015 SRP meets the stande of safety expected and required by the BLM, we invite BRC to further engage in a mutual effort to improve event public health, safety, and security. As you know, I will be meeting with the Founders on March 17, 2015, at 10:00. I will be discussing the attachment with the Founders. In the afternoon of the March 17 and all day on March 18 BRC and BLM staff will further meet and coordinate on topics involving 2014, 2015, and out years. In regards to enhancing the focus and priority on health, safety and security, within 40 days of receiving this letter and enclosure, we would like BRC to prepare a report that outlines your proposed solutions to each of the public health, safety and security issues we?ve identified. Please plan to present your report and proposed solutions to me and the Winnemucca team, as well as the Nevada State Director, Office of Law Enforcement and Security and Washington Office leadership. These presentations will be scheduled once we receive your report but they will occur no later than April 24, 2015, in order to make the necessary adjustments prior to the 2015 Burning Man event. Thank you for your attention to this important issue; we look forward to working with you to improve the public health, safety, and security of the Burning Man event for 2015 and future years. If you have any questions regarding this letter and/or your forthcoming report/presentation, please contact me at 775?623- 1500. Sincerely, Gene Seidlitz District Manager Winnemucca District Enclosure cc: Larry Harvey, Marian Goodell, Harley Dubois, Will Roger Peterson, Michael Michel. Crimson Rose Honorable Congressman Amodei Safety, Health and Security Issues of 2014 Burning Man Event Safety, Health and Security Issues and Concerns 1. BBC Medical Program. BLM observed disorganized medical responses between Humboldt General Hospital (HGH) and Emergency Services Department (ESD) due in part to problems in the chain-of- command structure. In addition, per the HGH 2014 After Action Report (MR), problems exist with medical program assets and with the overall management and development of the program. BLM Law Enforcement (LE) and BLM Civilian Operations staff observed miscommunication, which led to the appearance of duplication of medical services between ESD and HGH and caused confusion. For example, if a civilian or law enforcement officer observed or responded to a medical incident they would communicate the incident, medical observation/injury, and request medical assistance through the BLM dispatch center. The BLM dispatch center would then communicate the medical request to the dispatch center that would dispatch ESD or HGH personnel. During the event, the dispatching of medical personnel is completed by and the appropriate medical response did not always occur. As a result, public safety was impacted by the confusion. During a rain event which closed the city in 2014, the plan to establish unified command was not followed properly. 2014 AAR, page 19, states, ?Given that a unified command system was not correctly stood up, the potential exists that crews, participants and others were exposed to added hazards given the failure of not including all critical partners in the UC organization. In subsequent years it is essential that a more collective approach be taken during any type of critical incident.? On page 3 of the Operational Assessment (Weather Event) this issue was further highlighted. As a result, public safety was impacted by the lack of effective unified command (UC). ESD dispatchers were not properly qualified. 2014 page 22, states, ?The lack of standardized training, familiarity with emergency communications, and the lack of sufficient emergency dispatch certifications and/or licensure created a number of hurdles for emergency responders during the 2014 event.? As a result, public safety was impacted because of these identified communication issues. Either there were not enough emergency response vehicles available or the available vehicles were not efficiently assigned. 2014 MR, page 20, states, ?At several times during the event the EMS Operation reached a "Status Zero" state (no units available), during these times QFle (Quick Response Vehicles) and Command Units were utilized to answer calls.? As a result, public safety was impacted by the availability of emergency equipment such as ambulances. 2. BRC Fire, Rescue, Hazmat Programs. BLM and HGH observed and reported shortcomings in equipment and management of fire, rescue and hazmat programs. 2014 AAR, page 23, states, ?Currently the technical rescue and extrication capabilities of the on playa response system are of great concern, do not meet national standards, are antiquated, and are not As a result of the lack of standard extrication capabilities, public safety was impacted. During the response to the fatality during the event, BLM LE communicated to BRC the need for the clean?up of bodily fluids. BRC was disorganized in their response, and BRC staff assigned refused to do the cleanup without respirators. Hazmat procedures must be better defined, and staff available to complete work with proper equipment. 3. Fatality Medical Response and On-Scene Management. BLM and other cooperators observed and reported disorganized and unprofessional medical response and scene management during an accident in which a woman was run over and killed by the trailer of a roving art car. On page 3-4 of the Operational Assessment (Fatality) this issue was highlighted. It was also discussed in the HGH 2014 AAR, page 18, which describes the event as it unfolded (When a) non-licensed ESD Field Supervisor disagreed (with the incident commander), he became hostile towards HGH staff, attempted to take over the scene, and acted in an unprofessional manner. LE on scene identified communication and chain of command issues when they observed ESD personnel disagreeing with the medical director?s assessment of the deceased patient. ESD and Black Rock Ranger (BRR) personnel began to interfere with what had quickly transitioned from a medical incident to a law enforcement incident with a crime scene that needed to be protected. At one point, BRC personnel had to be physically restrained by HGH staff to prevent interference with the crime scene, body, and other HGH medics. The inappropriate and confused response to this incident showed a lack of professionalism, management control and proper procedures. 4. Transportation Management. During a 15 hour city closure caused by a rain event, hundreds of vehicles were left stranded on the roads and highways leading to the event. UC members observed there was a lack of contingency planning for off-site traffic to address public safety on roads and highways leading to and from the event during this type of incident. This lack of contingency planning resulted in public safety problems. This issue was highlighted and discussed on page 3 of Operational Assessment (Weather Event). 5. Art Project Management. BLM LE and Civilian Operations staff observed public safety issues associated with art burns in 2014. During the ?Man? burn the upright supports were so thick that it took a prolonged time for the piece to fall, which led to concerns voiced by BRC about its staff?s ability to hold the crowd back to a safe distance. BRC requested that BLM LE remain on site to assist with crowd control until the Man structure safely fell. The art piece ?Embrace? was constructed with material that was too thin to burn per engineering guidelines. BRC told the artist it would not be allowed to be burned and the artist agreed. It was later brought to the attention by BBC that there was a high likelihood the art piece would be set on fire illegally by participants. Due to the inability to prevent the uncontrolled burning of the art piece by participants. a serious public safety hazard was created. To protect public safety, the U0 and BBC agreed that the piece would be burned under special circumstances. Operational Assessment (Embrace Art Burn) noted this issue on page 4. 6. Security and Safety Plan for Scheduled Burn Events. utilizes staff known as ?Sandmen? to physically prevent spectators from approaching the bums before it is safe to do so. However, BRC informed BLM that the Sandmen are not licensed, bonded, insured or trained to use any type of physical force to detain participants at Burning Man. communicated to BLM that the Sandman?s Standard Operating Procedures (SOPs) states that after interceding a participant attempting to enter a burn, they are released back into the crowd rather than detained. BLM has questions regarding the legal authority of staff providing security and detaining participants around art burns. Public safety is compromised by the lack of legal authority, and SOPs which threaten participant safety. 7. Sanitation Management. BLM LE and Civilian Operations observed and reported human waste on the open playa associated with mobile rave participants who did not have convenient access to portable toilets. Insufficient resources were dedicated to removing blackwater from participant campsites. Public health is compromised by insufficient portable toilets where they are needed and insufficient blackwater pumping resources throughout the city. These issues were also noted on page 37 of Operational Assessment (Environmental Compliance Recommendations). The Nevada Department of Health and Human Services? AAR, page 4, states, few theme camp participants registered complaints about the limited availability of septic tank pumping services." Also stated on page 5, ?Throughout the event empty hand sanitizer containers continued to be found at the port?a-potty banks. particularly on the 6-10 o?clock side of the No hand sanitizer was installed on the posts at the open playa port-a?potty banks until this (was brought) to the attention of the Burning Man organization must stress the importance of properly setting-up and stocking hand sanitizer with Public health is compromised by a lack of functioning hand sanitizing stations. Also noted throughout the event were sporadic and untimely schedules for daily pumping of porta potties. 8. Early Arrival Program. early arrival pass program for participants involved in the construction of large art projects, large art cars and large theme camps has grown to allow in excess of ten thousand people in the city before the official gate opening and start of the event. In 2014, the BLM observed a large number of early arrival pass participants not complying with the intent of the early arrival construction mission. The day before the main gate opened, provided BLM with their 8:00 am. population statistics report that showed 13,545 early arrival pass participants on playa. BLM Rangers and other BLM staff were surprised by the high number of people on the playa throughout the early arrival period who appeared to be partying, bicycling, playing music, and driving around in art cars, rather than fulfilling the intent of the early arrival pass program of construction. BBC and Burning Man participants should adhere closely to the intent of the early arrival program. operation, including both LE and Civilian Operations, will need to begin earlier and with increased staff in order to provide an adequate level of public safety and permit compliance if this trend continues. 9. D-Lot Design and Management. D-Lot is a large parking area located along Gate Road used for the purpose of staging vehicles and participants who are not immediately allowed to enter the event for a variety of reasons. D- Lot at times contains hundreds of vehicles. The footprint of D-Lot is a large fenced-in area. D- Lot has become a massive overflow parking area with no BRC internal organizational structure or directional markings to allow for effective location of emergency incidents. BLM LE and BLM Civilian Operations staff observed public safety issues including uncontrolled partying, loitering and trespassing. The design of D-Lot makes it very difficult for BLM law enforcement or EMS to respond to or locate calls, compromising public safety systems. A number of people in D-Lot were attempting to obtain tickets, and remained partying in D-Lot after they were told no tickets were available. In one example, the Pershing County Sheriff?s Office and BLM Law Enforcement received a call for service to assist Black Flock Flangers with a mentally disturbed/barricaded subject located in D-Lot. This incident was not immediately reported to BLM LE, as it would have been in the city, because of the unmanaged nature of D- lot, which exacerbated and extended the incident. A large crowd of people from within the D-lot area gathered around the incident and observed law enforcement interact with the subject. None of the people in D-Lot were accounted for in population counts or site occupancy reports. This poses public safety issues because of the unknown and high numbers of people in D-Lot, the types of activities they engage in and D-lot?s disorganized layout. Also in Operational Assessment page 3 (Barricaded Subject) BLM noted issues/concerns of the lack of BBC oversight/management of D-Lot. 10. Fuel Storage Management. In 2014, roaming art cars were observed with large amounts of onboard stored fuel. Additionally, some art cars include pyrotechnic effects in close proximity to stored fuel. Camps throughout the city were observed with large amounts of stored fuel for use in generators and other equipment. In some cases, the fuel was observed in unapproved containers. These issues increase the risk for a major fire incident, and pose a serious threat to public safety. 11. Deployment of Medical Resources. Inadequate proactive deployment of EMS assets was provided to large events in the city such as mobile raves and scheduled burns. BLM LE observed that medical resources were not adequately pre-staged at mobile raves and as a result BLM and County law enforcement officers were tasked with providing emergency care on a regular basis. Forward deployment of medical resources to large events and mobile raves will improve emergency response time by ESD, and reduce involvement in medical situations, thereby allowing LE to continue their law enforcement mission. 12. Placement of Emergency Vehicles at the Airport. It was observed by members of LE and Incident Commander that there were no dedicated emergency response vehicles located at the airport, which becomes one of Nevada?s busiest during the event. In the event of an airport emergency, a lack of immediate response could compromise public safety. Airplane crashes at the Black Rock City airport have occurred in the past, including this year. 13. Highway 34 Road Conditions. Hwy 34 was not designed to accommodate the amount and type of traffic generated by the event, leading to the deterioration of the road. If Hwy 34 fails completely during the event, it could pose a serious public safety issue as drivers could encounter damaged roadways leading to accidents, vehicle damage, long delays or becoming stranded if the roadway becomes impassable. The Washoe County Community Services Department AAR, page 6, states, ?Simply put, the road was never constructed for use on this scale. It has outlived its useful life and in order to avoid more disruptive and costly interruption to this critical artery to the Burning Man event and residents and visitors to the valleys north of Gerlach that immediate financial planning should be committed to a capital reconstruction project on this road." Without a capital reconstruction of the road, public safety will continue to be compromised by the deterioration of the road. 14. Population Tracking and Reporting Program. BLM Civilian Operations staff noted that BRC was unable to fulfill the intent of the Special Recreation Permit (SRP) Stipulations requiring accurate and timely population reporting before, during and after the event, despite numerous reminders to do so. The 2014 BLM Special Recreation Permit (SRP) Evaluation, page 2, states that population tracking and reporting program was inadequate and did not meet the BLM full requirements or SRP stipulations. As a matter of public safety, BLM must have an accurate population count, up to the minute when requested, in order to insure appropriate response to any major emergency that may occur. 15. BRC Event Table of Organization. BLM requires a detailed Table of Organization (T0) of management program at least 45 days in advance of the event. In order for BLM to effectively respond to emergencies it is necessary to quickly identify and contact specific BRC staff in various departments down to the field supervisor levels. The lack of a detailed TO compromises public safety. 16. BBC Event Management Program Description. BRC does not have a sufficiently detailed event management program description in their Plan of Operations. In order to ensure SFIP compliance, BLM needs a more detailed description of event management program outlining each operational division?s mission and scope, roles and responsibilities, supervisory controls and training program. In order to effectively respond to event management issues, BLM needs to refer to a detailed program management descnp?on. 17. Participant Evacuation Contingency Plan. A comprehensive participant evacuation contingency plan has not been developed with affected cooperators. BLM, BBC and the other cooperators need to develop a contingency plan in the event of an emergency which requires the city to be evacuated. Without an evacuation contingency plan public safety is compromised. 18. Significant Incident Reporting. Significant incidents were not reported in a timely manner as required by BLM. In 2014, BLM staff learned of an on-playa airplane crash that occurred during post event through a report on the television news. Also in 2014, during the incident with a barricaded subject. as described in #9 of this report, BLM LE was not notified until hours after the incident began which extended and exacerbated the threat to public safety. In other incidents, an art car collision with a pedestrian was not reported to BLM, and several medical evacuations which occurred during pre-event were not reported to BLM until days later. Black Rock Rangers who encounter violations of the law need to immediately contact the appropriate law enforcement agency on playa. Lack of timely incident reporting compromises public safety. 19. Art Car Operations. BLM LE observed art cars operating on crowded streets in the city, increasing the potential for collisions with pedestrians and bicyclists. Art cars operated on the open playa during periods of limited visibility, which also increases the potential for collisions. Some large art cars have designs with exterior ladders and stainrvells leading to upper decks, which encourages some participants to get on and off while the art car is still moving. Some pyrotechnic art cars carry stored extra fuel which creates hazards of both fire and explosion. Pyrotechnic art cars operate on the city streets in close proximity to inflammable structures. Art car ?spotters? who help direct large moving art cars with limited driver visibility were observed without high visibility clothing during the day and without flashlights at night, creating a public safety hazard. These art car issues compromise public safety. 20. Illicit Narcotics. Law enforcement and medical workload is increasing in order to address participant behavior and health while under the influence of controlled substances, which creates a public safety issue for employees and participants. Often the first responders to drug-related complaints at mobile raves and large parties are law enforcement officers. This takes up large amounts of time, and prevents officers from continuing with their regular duties, which could lead to increases in law enforcement staffing levels. The Operational Assessment, page 4 (Use of Dangerous Drugs), notes the use of dangerous drugs comprises the safety, health and security of everyone at the event. The 2014 HGH AAR, page 25 states, ?Medical professionals report an increase in what appears to be the use of illicit drugs, and GHB. These illicit drugs can cause life threatening complaints and require immediate clinical intervention.? Illicit drug use is a threat to public safety.