Written Testimony
Submitted by U.S. Chemical Safety Board Chairman Rafael Moure-Eraso to the
Joint Committee: Senate Committee on Environment and Public Works and the
Senate Committee on Health, Education, Labor, and Pensions hearing entitled,
"Oversight of the Implementation of the President’s Executive Order on
Improving Chemical Facility Safety and Security”
The
CSB is an independent federal agency that investigates major chemical accidents
and hazards and develops safety recommendations to prevent their recurrence in
the future. The Board is a non-regulatory, scientific, investigative agency. It
has an annual budget of $11.0 million and approximately 38 employees. In
addition to investigations, safety studies, and recommendations, we do
extensive outreach to companies and other organizations to inform them of our
findings. Companies throughout the U.S. and the world use the reports, online
videos, and recommendations developed by the CSB to help create what we hope
are safer workplaces.
Congress
frequently calls upon the CSB to investigate the root causes of some of the
most complex and tragic industrial accidents across the country including the
2012 Chevron refinery fire in California and the 2014 chemical release in
Charleston, West Virginia, that contaminated the drinking water supply for
300,000 residents. The CSB is also investigating a number of additional
catastrophic accidents across the country including the fatal ammonium nitrate
explosion in West, Texas, and the fatal explosion at the Williams Olefins
facility in Geismar, Louisiana, both in 2013.
In
January 2014 I authored a New York Times opinion article entitled “The Next
Accident Awaits” where I noted that the current process safety regulatory
system is in need of reform. Tragically there was not too much time spent
waiting for the “next accident” – in November 2014 four workers were killed outside
Houston in a large-scale toxic gas release from a DuPont pesticide plant.
The CSB is now investigating this accident.
After
the West explosion, President Obama issued an executive order requiring federal
agencies to review safety rules at chemical facilities. I am encouraged
by the leadership of the White House, OSHA, and EPA in taking the first steps
towards reforming U.S. process safety management regulations. Today’s
joint committee hearing is an excellent opportunity to learn more about how the
reform of existing process safety standards is moving forward. To date,
both OSHA and the EPA have issued Requests For Information (RFI’s), and may
soon initiate rulemaking to revise the PSM standard and the RMP
regulation. I support these efforts. The CSB submitted a
comprehensive response to each RFI detailing needed improvements to the
existing federal process safety management regulations.
The
reality is that U.S. process safety management regulations have undergone no
substantive improvements since their inception in the 1990’s. Moreover
other existing OSHA standards governing explosives like ammonium nitrate,
flammable and combustible liquids, and hot work are even older, dating from the
early 1970’s, and are based on fire code guidance from the 1960’s. These
regulations have not been updated since, even as the voluntary fire codes have
undergone many cycles of revision and improvement. The CSB has noted in its
recent investigations of major incidents that both the OSHA Process Safety
Management (PSM) standard and the EPA Risk Management Plan (RMP) Program
regulations appear to function primarily as reactive and activity-based
regulatory schemes that require extensive rulemaking to modify, resulting in
stagnation despite important lessons from accident investigations, advancing
best practices, and changing technology.
More
must be done to ensure that a comprehensive process safety management system is
in place in the U.S. to protect worker safety, public health, and the
environment. There must be greater emphasis from regulators and companies on
preventing the occurrence of major chemical accidents through safer design and
elimination of hazards.
The
2012 fire and explosion at the Chevron Refinery in Richmond, California, that
sent approximately 15,000 residents to seek medical attention and endangered
the lives of 19 workers was entirely preventable. Chevron’s own employees
had repeatedly notified company officials of the corrosion hazard (which
ultimately caused the failure of a major pipe carrying hot hydrocarbons), but
unfortunately this did not result in replacing the corroded piping with
inherently safer, corrosion-resistant materials that were known to industry and
recommended in voluntary practices.
This
accident has set off a series of regulatory reforms in California, which can
serve as a model for the modernization of process safety management at the
federal level. California is taking important steps towards modernizing
process safety management by funding additional PSM inspectors and by issuing
draft process safety management regulations that address many of the attributes
of a stronger regulatory system identified by the CSB’s investigative
reports. In October, California’s legislature passed, and Gov. Jerry
Brown signed, a sweeping law requiring the state's petroleum refineries to
provide regulators with detailed information concerning extensive maintenance
overhauls and repair operations – known in the industry as turnarounds. This
important reform will help prevent accidents by ensuring that needed repairs
will be more promptly conducted rather than deferred as we found in our Chevron
investigation.
I
commend California for taking action in the wake of the Chevron fire. In
my view, had these new laws and regulations been in effect before August 2012,
California's Division of Occupational Safety and Health, or Cal/OSHA, could
have urged or required the safety improvements needed to prevent the accident.
To
continue to advocate for further reforms, the CSB recently added the issue of federal
process safety management reform and modernization to its Most Wanted Chemical
Safety Improvements Program. The goal of adding this important issue to the CSB
Most Wanted Program is the continuous improvement of process safety management
in the U.S. through the implementation of key federal and state CSB process
safety-related recommendations and lessons learned.
The
CSB has found that current federal and state regulations do not focus enough on
continuously reducing process risks. CSB investigations into serious accidents
including the Tesoro explosion and fire in Anacortes, Washington, and the
Chevron Refinery fire found that there was no requirement to reduce risks to a
specific risk target such as “As Low As Reasonably Practicable” (ALARP), which
is the standard applied in Europe and elsewhere, where major accident rates are
much lower. Similarly, there is no mechanism to ensure continuous safety
improvement; no requirement to address the effectiveness of controls or to rank
the effectiveness of preventive measures (also referred to as the hierarchy of
controls); and no requirement to implement and document an inherently safer
systems analysis in establishing safeguards for process hazards.
The
CSB investigation reports on these incidents noted that there should be an
increased role for workers and worker representatives in process safety
management and that similar to recent actions in California, where the force of
specialized refinery safety inspectors was tripled, the regulator must have the
tools and technically competent personnel to conduct preventative inspections
and audits.
We
have often heard the argument that the major accidents of recent years are the
result of mistakes by what some have called “outlier” companies. Most
recently, this argument has been floated in industry comments responding to
OSHA and EPA’s requests for information on safety regulatory reform.
Small companies like West Fertilizer in Texas and Freedom Industries – the
small terminal operator whose leak contaminated West Virginians’ drinking water
– are unaware of rules and good practices, are not members of national trade
associations or subscribers to their voluntary programs, and generally fly
beneath the regulatory radar – so the argument goes. One trade association,
in its comments, went so far as to say that the massive explosion at BP’s Texas
City refinery in 2005 was an “outlier” event, even though this was at the time
the third largest oil refinery in the country, owned by one of the world’s
largest and most technically sophisticated corporations.
There
should be no mistake – process safety disasters are not limited to any
so-called outliers. These disasters – which
no one wants to occur – are the result of many factors affecting
large and small companies alike. These include: weak or obsolete
regulatory standards, inadequate regulatory resources and staffing, overly
permissive industry standards, and a lack of safe design requirements and risk
reduction targets.
The
most recent example is the tragic chemical accident at the major DuPont
chemical plant in La Porte, Texas, just east of Houston. On November 15,
2014, there was a release of methyl mercaptan, a highly toxic and volatile
liquid, which DuPont itself has estimated at 23,000 pounds – a very significant
quantity. Odors of the chemical were reportedly discernible many miles
from the plant. Four workers – including operators and would-be rescuers
– perished inside the methomyl-production building where the release
originated.
DuPont
is certainly no “outlier.” In fact, DuPont has long been regarded as one
of industry’s leading lights in safety, and it markets its safety programs to
other companies. What happened last month, however, was the fifth release
incident at a DuPont facility that the CSB has investigated since 2010, and
three of these had associated fatalities. While the CSB investigation
remains underway in La Porte, some preliminary facts are already emerging.
The
incident occurred following an unplanned shutdown of the methomyl unit due to
inadvertent water dilution of a chemical storage tank several days
earlier. Efforts were underway to restart the process, but problems
occurred including plugged supply piping leading from the methyl mercaptan
storage tank. As efforts were underway to troubleshoot these problems, it
is likely that methyl mercaptan (and possibly other toxic chemicals)
inadvertently entered the interconnected process vent system inside the
building. The release occurred through a valve that was opened as part of
a routine effort to drain liquid from the vent system in order to relieve
pressure inside. We found that this vent system had a history of periodic
issues with unwanted liquid build-up, and the valve in question was typically
drained directly into the work area inside the building, rather than into a
closed system. In addition, our investigators have found that the
building’s ventilation fans were not in service, and that the company did not
effectively implement good safety practices requiring personnel to wear
appropriate personal protective equipment (PPE) that was present at the
facility. Appropriate PPE would include equipment, such as supplied air
respirators, for workers performing potentially hazardous tasks inside the
building.
In
summary, this was a complex process-related accident with tragic results.
It gives rise to a number of design and organizational safety concerns.
Its occurrence – taken along with other major accidents afflicting large and
small corporations – underscores the need for some systemic reforms. It
would be a serious and tragic mistake to consider each of these accidents as
just another isolated event, reflecting only the limited practices of a small
group of people operating outside regulatory scrutiny. If it can happen
at DuPont, I would submit it can happen anywhere.
In
June 2013 I testified before the Senate EPW Committee on the CSB’s ongoing
investigation into the West, Texas, ammonium nitrate (AN) explosion that
tragically killed 15 people and caused hundreds of injuries, and devastated
much of the town including homes, schools, businesses, and health care
facilities. The explosion followed an intense fire that consumed a wooden
storage building that held tons of fertilizer ammonium nitrate in wooden
bins. At that time I noted the existing patchwork of U.S. safety
standards and guidance for such facilities: a patchwork that has many large
holes, including allowing the use of combustible wooden buildings and wooden
storage bins, few requirements for sprinklers (there were none at West), and no
federal, state, or local rules restricting the storage of large amounts of
ammonium nitrate near homes, schools and hospitals.
Voluntary
guidance provided by the Agricultural Retailers Association and The Fertilizer
Institute as well as an ammonium nitrate safety advisory issued in August 2013
by OSHA, EPA, and ATF are definitely positive steps in addressing the hazards
associated with the storage of AN. But they are not enough by themselves.
It is sobering to reflect that nearly two years after the West disaster, very
little if anything has changed in terms of federal, state, or local
requirements for ammonium nitrate handling and storage. These practices
still lag behind the ammonium nitrate safety practices of other countries, as
well as the good practice guidance of the U.S. explosives industry, which has
advocated commonsense safeguards like noncombustible storage buildings and
sprinkler systems to prevent fires that can sensitize ammonium nitrate to
explosion. Meanwhile fires continue to occur threatening ammonium nitrate
stored in wooden buildings, such as a recent fire at a fertilizer distributor
in Athens, Texas, that mercifully did not cause an explosion in the middle of
that town.
Industry
and government have increased their efforts to prevent major chemical
accidents. But CSB investigations show that much more needs to be
done to assure that future tragedies will be avoided – the
opportunity for meaningful reform is now. Thank you for the opportunity
to submit written testimony for this important hearing today.
