U.S. Postal Service: Guidance on Suspicious Mail Needs Further	 
Refinement (19-JUL-05, GAO-05-716).				 
                                                                 
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.			 
-------------------------Indexing Terms------------------------- 
REPORTNUM:   GAO-05-716 					        
    ACCNO:   A30298						        
  TITLE:     U.S. Postal Service: Guidance on Suspicious Mail Needs   
Further Refinement						 
     DATE:   07/19/2005 
  SUBJECT:   Employee training					 
	     Hazardous materials emergency response		 
	     Hazardous substances				 
	     Health hazards					 
	     Occupational safety				 
	     Postal service					 
	     Postal service employees				 
	     Strategic planning 				 
	     Policy evaluation					 
	     Emergency preparedness				 
	     Postal facilities					 
	     Mail security					 
	     National Response Plan				 
	     USPS Integrated Emergency Management		 
	     Plan						 
                                                                 

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GAO-05-716

United States Government Accountability Office

 GAO	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

                                       a

GAO-05-716

July 2005

U.S. POSTAL SERVICE

Guidance on Suspicious Mail Needs Further Refinement

[IMG]

  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.

Message on envelope and vial found inside

Sources: GAO (left graphic) and FBI (right photograph).

The envelope had a warning message typed on the outside. Inside was a
sealed vial containing a substance that tested positive for ricin.

               caution RICIN POISON Enclosed in sealed container Do not open 
                                 without proper protection                   

                 United States Government Accountability Office

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

1 3 6

8

18

32 47 48 49

Appendixes

     Appendix I: Scope and Methodology 52 Appendix II: Comments from the U.S.
         Postal Service 55 Appendix III: Contact and Staff Acknowledgments 58

  Related GAO Products

Tables	Table 1: Table 2:

Table 3:

Table 4: USPS Facilities Key USPS Guidance in Place on October 15, 2003 on
Identifying and Initially Responding to Suspicious Mail Extent to Which
Initial Response Actions Were in Accordance with Suspicious Mail Guidance
and Procedures for Handling Mail Containing Hazardous Materials Key USPS
Guidance on Identifying and Responding to Suspicious Mail Developed or
Issued After October 2003 Incident

6 19

26 34

Figures Figure 1: Figure 2:   October 2003 Timeline of Greenville    10 11 
                                   Incident Message on the Envelope     
                     Figure 3:  Photo of the Sealed Vial Found Inside      14 
                                             the Envelope               
                     Figure 4: Comparison of Instructions in Suspicious 
                                                 Mail                   
                                               Guidance                    22 
                     Figure 5:           USPS Three Ps Poster              36 

Contents

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

This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed in
its entirety without further permission from GAO. However, because this
work may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this material
separately.

A

United States Government Accountability Office Washington, D.C. 20548

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.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.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

1We 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).

2Biological 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.

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.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:

o 	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?

o 	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?

o 	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

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

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.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 Number Description

Processing and 348 Process and dispatch incoming and outgoing mail
Distribution Centers and for a designated service area
Facilities

Airmail Centers and 78 Receive, distribute, and dispatch mail transported
Facilities principally by air

Bulk Mail Centers 21	Process and distribute bulk standard mail and parcels

Priority Mail Processing 12 Process priority mail Centers

Post Offices, Stations, 37,159 Collect, distribute, and deliver mail and
Branches

Source: USPS.

4Ricin 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.

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.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

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

o 	installing biohazard detection systems at some processing facilities
and developing and implementing related procedures and training of
personnel;6 and

o 	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.

5GAO 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).

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

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.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.

7Joint 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.

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

Source: GAO analysis of USPS, Inspection Service, FBI, South Carolina
Department of Health and Environmental Control, CDC, and DHS data.

aThe envelope had previously been double-bagged by postal personnel.

USPS Personnel Discovered About 12:15 a.m., on October 15, 2003, an
employee at a postal airmail and Initially Responded to facility in
Greenville, South Carolina, discovered a standard business size the
Suspicious Envelope on envelope, measuring 4 inches by 9 inches, on a mail
processing machine.

The employee noticed that the envelope bore only a written warning on
theOctober 15 outside of the envelope and had no postage, addressee or zip
code, or return address. (See fig. 2.)

                       Figure 2: Message on the Envelope

caution RICIN POISON Enclosed in sealed container Do not open without
proper protection

Source: GAO graphic based on an FBI photo.

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

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.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, doublebagged 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.

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

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.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.10 (See fig. 3.)

9According 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.

10The 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)

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

Source: FBI.

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.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.

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

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.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

12The 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.

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 At the time of the incident in Greenville,
key Postal Service guidance on

Initially Responding to suspicious mail included two documents- "decision
trees" and a poster-

Suspicious Mail	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 Intended Date issued or
guidance audience updated Description

                               Guidance documents

                                               Presented separate sets of     
Decision trees Managers and October 2001  actions to take, in a flowchart  
                                                  format, in incidents        
                                            involving a suspicious            
                  supervisors               unopened/sealed mail piece and in 
                                            incidents involving an            
                                                    open mail piece leaking a 
                                Updated in         suspicious powder. a Also, 
                                               included different actions for 
                                                small and large facilities to 
                                March 2003         take during either type of 
                                                 incident. Developed based on 
                                                     CDC advisories.          

Suspicious mail All employees October 2001 Portrayed, in a one-page poster
with a photo, how to identify a suspicious mail

poster and the public piece and key actions to take upon discovery. Also,
presented additional separate Updated in guidance for situations involving
a suspected bomb, radiological threat, or March 2003 biological or
chemical threat.

Training

                                                 Presented actions to take in 
     Suspicious       Managers,     April 2003          incidents involving a 
                                               suspicious powder leaking from 
                                                a mail piece. Consisted of a  
powder tabletop supervisors, and            series of scenarios portraying 
                                                        phases of a           
                                               hypothetical incident and      
      exercise      support staff              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.

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

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:

o  Lopsided or uneven.

o  Powdery substance on the outside.

o  Odors, discoloration, or oily stains.

o  Excessive postage or tape.

o  No return address.

o  Handwritten or poorly typed address.

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

o  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

                                         Suspicious mail poster   Suspicious  
                    Decision tree for a              Mail with a    powder    
                        suspicious      General      suspected     tabletop   
                      unopened/sealed   suspicious   biological    exercise   
                    envelope or parcel  mail         or chemical  traininga   
                                                     threat      
      Number of                                                               
suspicious mail           9               12         Same          13
characteristics                                               
                                        0M Rigid or                Postmark   
Characteristics   0M Loose sifting     bulky 0M                 does not   
that appear only     material 0M      Excessive      Same        match     
    in identified   Threatening message   tape 0M                  sender's   
       guidance                         Sealed with                address    
                                            tape                 
                                        Handle with                 Do not    
                       Do not handle    care Do not                disturb    
                          further         shake or                powder in   
                                            bump                   any way    
                                        Do not open,             
                      Do not shake or      smell,                
                      empty contents     touch, or               
                                           taste                 
                    Isolate the package  Isolate it    Isolate   
Initial response   without further   immediately     Don't    
actions                contact                      handle    
                      Leave area and                  Evacuate     Prevent    
                    prevent others from               immediate  others from  
                         entering                       area       entering   
                                                     Wash hands   Wash hands  
                      Wash hands with                 with soap   with soap   
                      soap and water                  and warm    and water   
                                                        water    
                                        Treat it as              
                                          suspect                
                                                                   Contact    
                    Contact supervisor                            supervisor  
                       if availableb                              as soon as  
                                                                   possible   
                                                                  Supervisor  
                                                                 contacts in  
                                                                  order: 0M   
                                                       0M Call    Inspection  
                                                      police 0M   Service 0M  
Notification of                                     Contact   Local police 
        others         Supervisor or    Call local     postal        and      
                     employee contacts  law          inspectors   hazardous   
                       in order: 0M     enforcement    0M Call     material   
                    Inspection Service  authorities  local fire  contacts 0M  
                    0M Local police and              department   Postmaster  
                    hazardous material                hazardous      (who     
                        contacts 0M                   materials    contacts   
                     Postmasterc (who                   unit       district   
                     contacts district                           manager) 0M  
                    manager) 0M Safety                              Safety    
                          officed                                   office    
                    Building occupants                           If facility  
                    should remain in a                           manager has  
                    place of refuge                               called the  
                    away from the mail                              local     
                    piece and await                              responders,  
                    emergency                                        then     
                    responders. In                                 maintain   
Other response   large facilities,                             isolation   
actions          the spill and leak                            around the  
                    team examines the                             spill site  
                    scene, attempts to                            and place   
                    determine if an                              all building 
                    emergency exists                             occupants in 
                    and takes defensive                           a place of  
                    actions (tape off                            refuge away  
                    area, shutdown                                 from the   
                    ventilation, etc.).                             spill.    

Source: GAO analysis of USPS suspicious mail guidance.

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

aThese 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.

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

cAccording 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.

dThe 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.

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.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, In addition to the guidelines described above,
which were aimed at taking

Handling, and Responding to precautions against possible threats in the
mail, USPS had "hazardous

Hazardous Materials in the Mail	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 itto another area.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

13The version in the April 2003 training exercise was titled "Decision
Trees for Anthraxrelated Emergencies."

14A 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.

              Guidance on Communicating with Employees and Unions

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.

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.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,

15In 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.

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.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

                                                              Were actions in 
                                                                   accordance 
                                          Were actions in     with hazardous  
                                          accordance with        material     
Time period       Actions taken          suspicious mail      handling     
                                              guidelines?       procedures?   
12:15 a.m.  Employee separated                                   Yes       
               envelope from other mail      Yes - postera    
       to        and brought it to her    No - decision treeb 
                      supervisor.                             
    1:00 a.m.                                                 
               Supervisor isolated               Yesc                         
               envelope, cordoned off the                           N/A
                  area, and evacuated                         
                       employees.                             
                 Employee instructed to           Yes               N/A       
                     wash hands. d                            
               Based on instructions from         No                Yes       
               the facility manager,                          
               supervisor moved envelope                      
                    to a conference                           
                         room.                                
               Based on instructions from         No                Yes       
               the facility manager,                          
               supervisor allowed                             
               employees to return to                         
               work                                           
                         room.                                

16The 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.

(Continued From Previous Page)

Were actions in accordance Were actions in accordance with with hazardous
material Time period Actions taken suspicious mail guidelines? handling
procedures?

8:00 a.m.  Facility manager contacted:      No (did not call in order  N/A 
to         o  Safety officer at 8:10 a.m.   recommended and calls      
                                               delayed)                   
12:00 p.m.    o  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)                                       
              o  Postmastere at 11:00 a.m.                                
              o  Local police at 12:00 p.m.                               
              (contacted after                                            
              speaking with inspector)                                    

Spill and leak team examined scene at 9:00 Yesf N/A
a.m., double-bagged the envelope, put it in a
separate room, and put "Do Not Enter" signs on
the doors.

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.

aThe 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.

bThe 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.

eThe 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.

fHowever, 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.

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.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.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.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

17USPS 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.

18According 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.

19In 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.

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.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.21 Union officials
told us that,

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

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

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:

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

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

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

o  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 Intended
guidance audience Date issued Description

                              Guidance documentsa

                                              Cites the ricin incident and    
Postal bulletin Managers and October 2003  emphasizes key steps for        
                                              responding to a                 
                                                suspicious mail piece. States 
     on handling   supervisors                     that the suspicious powder 
                                                              exercise can be 
suspicious mail                            applied to many suspicious mail 
                                                        incidents.            
       pieces                                 
                                              Presents characteristics of     
       "SLAP"                   November 2003 suspicious mail in four "easy   
                   Managers and               to remember"                    
                                                     categories, based on the 
     guidance on   supervisors                   acronym SLAP: unusual Shape, 
                                                                Look, Address 
     identifying                                  features, or Packaging.     
suspicious mail                            

                                                Presents "three simple steps" 
     "Three Ps"    Managers and October 2003   for responding to a suspicious 
                                                                     package: 
     guidance on   supervisors                o  Package - don't handle it.   
                                                    Isolate the area.         
                                             o  People - evacuate the area    
    responding to                            around the package and notify    
                                             your                             
suspicious mail                                     supervisor.            
                                             o  Plan - contact the Inspection 
                                             Service, police and community    
                                             first                            
                                                       responders.            

                                                  Presents the October 2003   
Suspicious mail All employees  February 2004     Three Ps guidance in a    
                                                       poster for USPS        
       poster                                             employees.          
                                                      Presents a checklist of 
                                 USPS plans to    actions to take in response 
      Response     Managers and  issue                 to suspicious mail and 
      checklist     supervisors   in late July        unknown powders or      
                                      2005              substances. b         
                                                        Presents the Three Ps 
      Poster on                  USPS plans to       guidance as well as more 
                   All employees issue              detailed instructions for 
                                                 employees, supervisors, and  
      immediate                  in early August managers on initial actions  
                                 2005                     to take in          
                                                 response to suspicious mail  
                                                    and unknown powders or    
      response                                          substances. b         
       actions                                   

Training

                                                      Updated version of 2003 
     Suspicious       Managers,     September 2004        training. Discusses 
                                                           actions to take in 
                                                                    incidents 
                                                   involving a suspicious     
powder tabletop supervisors, and                powder leaking from a mail 
                                                   piece. Consists of a       
                                                          series of scenarios 
      exercise      support staff                      portraying phases of a 
                                                    hypothetical incident and 
                                                                       active 
                                                   exercises in responding to 
                                                        these scenarios.      
                                                      Monthly mandatory talks 
                         All        November 2003   delivered by managers and 
Mandatory talks                                      supervisors to postal 
                                                   employees nationally.      
     on handling      employees                    Focuses on the use of SLAP 
                                                   and the Three Ps,          
                                                       respectively, for      
                                                   identifying and responding 
suspicious mail                                    to suspicious mail.     

Source: GAO analysis of USPS suspicious mail guidance.

aIn 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.

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

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

Source: USPS.

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.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.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

22According 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.

23See 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).

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:

o 	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.

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

o 	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.

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

o  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.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

24In 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-05001.

powder as well as non-leaking suspicious mail.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.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.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.

25To 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.

26A 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.

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

28The 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).

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 "allhazards" 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.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

29In 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 characteristivs 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.

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."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.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

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

31CDC 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.

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.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

32According 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.

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.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

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

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.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.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.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

34In 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.

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

36Occupational 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).

accurate and clear and provided in a timely fashion to prevent unofficial
sources, such as the media, from reporting information before official
sources.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.38 We have also
previously reported on the need to provide complete and timely
healthrelated information to postal workers to maintain trust and
credibility and to help ensure that workers have essential information for
making informed health decisions.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

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

38GAO-03-316.

39GAO, 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, GAO04-205T (Washington, D.C.: Oct. 23,
2003).

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.

o 	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.

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

o 	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

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

o 	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 http://www.gao.gov.

If you have any questions about this report, please contact me at
[email protected] 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,

Katherine A. Siggerud Director, Physical Infrastructure Issues

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:

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

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

o  Centers for Disease Control and Prevention (CDC).

o  Department of Homeland Security (DHS).

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

o  South Carolina Department of Health and Environmental Control.

o  American Postal Workers Union.

o  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

Appendix I Scope and Methodology

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

Appendix I Scope and Methodology

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.

                                  Appendix II

                     Comments from the U.S. Postal Service

Appendix II
Comments from the U.S. Postal Service

Appendix II
Comments from the U.S. Postal Service

Appendix III

                       Contact and Staff Acknowledgments

Contact Katherine Siggerud, (202) 512-2834 or [email protected]

Staff 	In addition to the above, Susan Fleming, Assistant Director;
Heather Balent; Colin Fallon; Scott Farrow; Judy Guilliams-Tapia; Daniel
Kaneshiro;

Acknowledgments	Jamie Meuwissen, and Matthew Mohning made key
contributions to this report.

Related GAO Products

Anthrax Detection: Agencies Need to Validate Sampling Activities in Order
to Increase Confidence in Negative Results. GAO-05-251. Washington, D.C.:
March 31, 2005.

21st Century Challenges: Reexamining the Base of the Federal Government.
GAO-05-325SP. Washington, D.C.: February 2005.

High-Risk Series: An Update. GAO-05-207. Washington, D.C.: January 2005.

U.S. Postal Service: Better Guidance Is Needed to Ensure an Appropriate
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9, 2004.

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Reopening the Brentwood Facility. GAO-04-205T. Washington, D.C.: October
23, 2003.

Bioterrorism: Public Health Response to Anthrax Incidents of 2001.
GAO04-152. Washington, D.C.: October 15, 2003.

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Exist to Enhance Contract Oversight. GAO-03-686. Washington, D.C.: June 4,
2003.

U.S. Postal Service: Issues Associated with Anthrax Testing at the
Wallingford Facility. GAO-03-787T. Washington, D.C.: May 19, 2003.

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GAO-03-118. Washington, D.C.: January 2003.

Diffuse Security Threats: USPS Air Filtration Systems Need More Testing
and Cost Benefit Analysis Before Implementation. GAO-02-838. Washington,
D.C.: August 22, 2002.

U.S. Postal Service: Moving Forward on Financial and Transformation
Challenges. GAO-02-694T. Washington, D.C.: May 13, 2002.

Related GAO Products

Highlights of GAO's Conference on Options to Enhance Mail Security and
Postal Operations. GAO-02-315SP. Washington, D.C.: December 20, 2001.

Homeland Security: A Risk Management Approach Can Guide Preparedness
Efforts. GAO-02-208T. Washington, D.C.: October 31, 2001.

Combating Terrorism: Observations on Biological Terrorism and Public
Health Initiatives. GAO/T-NSIAD-99-112. Washington, D.C.: March 16, 1999.

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