AMERICA’S INDUSTRIAL ACCIDENT INVESTIGATORS: THEIR UPHILL BATTLE TO PREVENT DISASTERS

By Jeff Johnson

Before dawn, Jim Gannon kissed his sleeping wife and kids goodbye and drove to work at the Napp Technologies chemical plant near his home in Lodi, New Jersey. There, like most mornings, he parked his car and headed off to his locker, but this morning Gannon was hit with the strong stench of rotten eggs. Hydrogen sulfide gas, he guessed, and he knew something was wrong. Gannon and his friend Buster McKenzie put on their protective face masks and both volunteered to go into the process room to check out the problem. They argued and McKenzie won, and while Gannon waited in a hallway outside, McKenzie went in and died.

“Everything got quiet, and then it was like the sun came into the hallway,” Gannon explained. “I was flying backwards, but my arms and legs were being sucked in opposite directions. I could feel my hair burning off, and the skin burning off my hands. But as hard as I could try, I couldn't pull them in. I felt like I was going to die, so I relaxed because I figured it would just be easier if I just let it happen, rather than trying to fight it.”

Gannon lived, but on that April day in 1995, McKenzie and four other Napp workers did not. He underwent years of physical and emotional therapy. The tragic Napp accident ruined his life and the lives of others. However, it led Congress to finally fund a small and independent federal agency created to investigate and discover the root causes of industrial chemical accidents.

This agency’s work is increasingly urgent, as the number and velocity of hurricanes rake American cities with large concentrations of industrial plants. The recent flooding of Houston caused an out-of-control fire at the Arkema Chemical Company there, endangering first responders, neighbors and the general public. Flood water caused the plant’s reactive chemicals to explode into fire, a situation this tiny federal agency has been trying to regulate without success for 20 years.

The Chemical Safety Board was written into law in 1990, five years before the Napp accident in New Jersey. But until 1998, Congress and two presidents refused to fund it. The Napp accident changed that. It was too horrible to ignore and it happened in New Jersey, a highly urbanized state with a history of industrial tragedies.

Because of pressure from New Jersey residents, unions, the governor and congressional delegation, CSB received $4 million. The funding got it started but it was a pittance considering the cost in dollars and lives lost or maimed from a single chemical plant or refinery explosion. It also was too meager considering what the board was expected to do.

The board is unique in the world. It is independent to protect its objectivity. It has no authority to regulate companies or enforce laws; it issues no fines. But it does select industrial accidents to investigate under a broad mandate to determine the cause and to recommend how to change industrial practices. Some 250 accidents occur each year that could quality for an investigation.

Its staff must have engineering and industrial skills and experience, poke around fresh accident sites, carry out complicated on-the-ground interviews and research, discover what went wrong and how to fix it, and write a final report. CSB’s recommendations can change the operations of plant managers and of government regulators, including much larger agencies such as the Occupational Safety and Health Administration (OSHA) and the Environmental Protection Agency (EPA).

CSB, however, is a perpetual industry nag. It has stepped on toes and does not have powerful friends. Its history says much about the difficulty in protecting residents living near factories and workers laboring in chemical companies, refineries and the multitude of businesses that handle potentially dangerous chemicals in America. To this day, huge accidents are the driving force keeping the board alive.

Many board recommendations have changed industrial behavior and regulations. CSB has investigated more than 90 industrial accidents and prepared some 30 influential safety videos. Its reports, videos and advisory bulletins have been used worldwide. It has discovered fundamental safety problems that have been ignored and publicized their solutions. Its problem is getting those solutions implemented.

Every presidential administration since George H.W. Bush has cut its funding requests and failed to fully enact its most far-reaching recommendations. This spring, President Donald Trump went even further and proposed to kill the board outright.

Through the years, CSB’s champion was the late New Jersey Democrat and U.S. Senator Frank Lautenberg. The board was a creation of Lautenberg’s through a provision he shepherded through a huge Clean Air Act of 1990.

Lautenberg feared a Bhopal-like accident would occur in the United States. In 1984, the American company, Union Carbide, exploded in Bhopal releasing a toxic gas and killing more than 2,000 Indians outright. Union Carbide ran similar pesticide plants in the United States, using the same chemical. Lautenberg was right to worry.

He had grown up and still lived near Lodi. Napp Technologies was his neighbor. He was a local boy; his father, uncle and grandfather had worked in the silk mills of Paterson, New Jersey. All had died of colon cancer in their 40s and 50s. When the Napp plant blew up, Lautenberg was there with the fire trucks, he said.

Lautenberg was speaking at a CSB hearing in Paterson in 2002, the same meeting where Gannon told his tragic tale. CSB called the hearing to discuss the Napp accident and its findings that the cause was similar to several other accidents, according to board member Gerald Poje. CSB proposed to focus new regulations on a certain class of common chemicals that were by themselves inert but could react violently when mixed together or subjected to excessive pressure and heat. It had completed an extensive survey of several reactive chemical accidents across America which were similar to Napp’s.

CSB’s survey found out-of-control reactions of these chemicals were responsible for at least 167 industrial accidents and the deaths of 108 workers over 20 years. The numbers were likely higher, board members said, as there is no decent database of industrial accidents. All of the accidents could have been avoided with better controls, knowledge, and regulations, according to Poje and other CSB officials.

Most importantly, CSB’s report showed that company operators and industry regulators had ignored the chemicals’ characteristics.

Along with Gannon, other workers spoke out at the hearing, describing similar reactive chemical accidents at Morton International, the former Morton Salt Co., also located in New Jersey, and Phillips Chemical Co. near Houston, Texas. At Morton, Richard Oliver was thrown some 40 feet in the air when two chemicals exploded after being mixed in a reactor vessel. The explosion sent a fireball into the neighborhood. Nine workers were injured in the blast, Oliver said, two were badly burned.

Allan Goss, a union safety official at Phillips was working on a grating 70 feet in the air to restart an operation that had been shut down nine months earlier after another accident killed two plant workers. The Phillips plant had a history of accidents. In 1989, 23 workers died and 314 were injured in one the nation’s most deadly incidents.

Goss was working near a tank that blew also sending a fireball into the neighborhood. Four men were on the grating; one died on the spot.

Goss flew through the air but remained on the platform with second and third degree burns across 50 percent of his body. But he was alive. He struggled to get down a ladder, using his arms, his hands were useless. He collapsed and lost consciousness and was flown to a hospital burn unit. He remained unconscious for three weeks and was kept in the burn unit for 101 days. Goss endured years of surgeries, burn treatment and pain.

CSB staff laid out its case for regulation. Unions supported it but industry did not.

Reactive regulations would be too difficult to implement, Don Connolley, manager of safety and health in the Americas for Akzo Nobel Chemicals, said at the meeting. He represented the American Chemistry Council, the largest U.S. trade association of chemical makers.

“Guidance and training on management of chemicals, and potentially reactive chemistry is the best way to minimize chemical reactivity incidents,” Connolley continued. Lists would be too unwieldly; performance-based standards too complex, he added.

Instead, he and other industry representatives endorsed guidance, educational documents and further research, not regulations. That theme was the industry’s mantra at the 2002 hearing and still is today.

A few months after the hearing, the chemical board recommended OSHA and EPA toughen their regulations to reflect its concerns about reactive chemicals. Despite much talk, to this day, neither has.

Support for these regulations has been a see-saw affair, according to Eric Frumin, who represented Napp workers as director of occupational safety and health for the Union of Needletrades, Industrial and Textile Employees. Today Frumin is director of health and safety for Change to Win, a broad coalition of labor unions.

Right after the Napp accident, unions petitioned OSHA to modify its regulations, Frumin says, and OSHA had been slowly and quietly developing a proposal to regulate reactive chemicals. In the waning months before President BillClinton left office, reactive chemical regulations were added to OSHA’s agenda for future regulations.

With the election of George W. Bush, however, reactives were dropped from OSHA’s agenda. The pattern was set—a horrific accident occurs, governments and regulators take notice, time marches on and everyone mostly forgets, until the next accident.

Accidents have continued as has the drumbeat from the chemical board and safety organizations for reactive chemical regulations. In another report, in 2007, the Chemical Safety Board found 249 reactive chemical accidents between 2002 and 2006. It only had resources to investigate 12 of them. Those resulted in three deaths, 220 injuries and the evacuation of 24,000 residents.

When quizzed about reactive regulations in 2010, David Michaels, the Obama Administration’s new OSHA head, announced that due to a lack of resources, regulation of reactive chemicals would not be considered. Instead, the agency would rely on more guidance directives and an inspection emphasis program to focus on these chemicals.

In 2013, CSB organized another general meeting to publicize the threat of reactive accidents and to prod OSHA. Because of a recent string of deadly accidents, a new entry was added to the meeting agenda—accidents involving a seemingly common and innocuous substance, dust.

Dust can be a fuel. Grains, fine metals and most solid organic material will burn or explode if finely divided, dispersed and mixed with oxygen. It can be a common industrial waste material—metal powders, wood and plastic pellets—found lying on floors, on overhead beams, in cracks, above false ceilings and elsewhere. When disturbed and in the presence of oxygen and an ignition source, dust explodes. In a dirty plant, the first blast often triggers a cascade, releasing more dust and more explosions.

It doesn’t take much. CSB found one-quarter of inch of dust was enough to kill six workers at a North Carolina pharmaceutical plant in 2003.

Dust had been on CSB radar since 2003 when it looked into three dust accidents that killed 14 workers. From 2008 to 2012, CSB documented 50 combustible dust accidents that led to 29 worker deaths and 161 injuries. Most horrendous, in February 2008, a series of sugar dust explosions and fires rolled through narrow passages at the Imperial Sugar refinery in Georgia, killing 14 workers, badly burning more than 30 others and causing hundreds of millions of dollars in property losses.

The Chemical Safety Board had urged OSHA to enact enforceable regulations to control industrial dust. What CSB wanted was similar to what OSHA had done in 1987, when it developed a set of regulations for combustible dust in the grain industry, noted former CSB Chairperson Rafael Moure-Eraso. This has not happened with industrial dust.

In the final years of the Obama administration, OSHA’s Michaels testified in 2014 to Congress that OSHA regulatory system was broken and needed an overhaul.

Reforming process safety regulations that control reactive chemicals or dust, he recently told me, is extremely difficult. “It would take years. Regulatory reform is a very slow, ponderous and byzantine process, and even before proposing a standard OSHA has to go through multiple steps. It must address technological and economic issues in studies that will take years and cost millions.”

Frumin disagrees.

“Instead of rules languishing, OSHA could issue a rule and finalize it in a couple of years—if it is given the political support it needs. If you don’t have support from political leaders, regulatory reform will take a lifetime.”

He points to a major process safety regulatory reform developed by the California Department of Industrial Relations and released this summer.

Following a fire and explosion at a Chevron refinery in Richmond, California in 2012 that sent 15,000 residents to Bay Area hospitals, the state began a reexamination of regulations for its 15 refineries.

CSB found the immediate cause was a corroded pipe. Chevron had known of the deficiency for a decade and did nothing. The board urged changes in California and local regulators’ safety policies.

In response, California Governor Jerry Brown ordered a review of refinery worker safety regulations. In August, the state announced a sweeping overhaul of refinery process safety regulations, along the lines of CSB recommendations that have been ignored by federal OSHA. It also increased the number of refinery inspectors.

“The key is political will,” Frumin noted. “CSB was born with a rush of passion,” he says. “But sustaining a passion is rough. CSB has many powerful enemies.

“Its lifeline has been a succession of disasters, each providing temporary support. These accidents have kept it alive but it is a rough way to live.”

The Trump administration remains committed to CSB’s elimination, but so far, congressional appropriators have recommended keeping the board alive with the same $11 million in funding. The pattern appears to continue, until the next big explosion.

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Families of the Dead Are CSB’s Biggest Supporters

CSB has many critics. But one group has remained steadfast in support—family members of workers killed in industrial accidents.

In 2003, Tammy Miser formed United Support and Memorial for Workplace Fatalities, a nonprofit that supports and provides guidance and resources to people whose world has been destroyed by a work-related accident.

“We try to help families out. After a family member’s death, we contact them to tell them someone is here. We help them get answers and comfort.”

She formed the group after her brother Shawn Boone, 33, died in a dust explosion in 2003 at the Hayes Lemmerz plant in Huntington, Ind., a manufacturer of aluminum automobile wheels. The accident was one of several CSB investigated that year.

No one told Miser about the accident. She only learned about the explosion and fire through a call from a friend. She rushed to the hospital but found there was no record of her brother’s arrival. A nurse told her, however, a male burned beyond recognition had come in without identification.

“There was no body hair, no physical markings,” she said the nurse told her.

“My Shawn was ultimately identified by body weight and type. We were told they were only keeping him alive for the family. They told us his internal organs were burned beyond repair. They could take his legs and take his arms but he wouldn’t make it, and it would just prolong his death. It was horrible but we took him off life support.

“His last words were ‘I am in a world of pain.’”

She wanted to know why he died. She tried to get OSHA to give her information about the company.

“OSHA told me I could file a request for penalties and inspection reports but it would cost two-hundred bucks—from a family that had just lost a loved one and their breadwinner.”

Miser worked to pass legislation to toughen safety regulations and to require the government help families after a family member’s death at work. The law failed but OSHA enacted a policy change in 2008 to provide free public information about companies and accidents to grieving families.

Unlike OSHA, the Chemical Safety Board cooperates with families, she says.

“We have gotten everything from them. All of it is open and they contact us and involve the families. Families have no knowledge of health and safety issues. I didn’t even know what OSHA was. Like me, they are just thrown into this when a family member dies.”

CSB, she adds, only has resources to investigate a small sliver of America’s industrial deaths.

“But,” she says, “it would be a tragedy if that is lost.”

@JeffJohnson2017.

Jeff Johnson, of Washington, D.C., is examining the federal Chemical Safety Board and its efforts to regulate chemical disasters under an Alicia Patterson Foundation grant.

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