Anniston Star
October 10, 2002

Army reveals Tooele mistake

By Matthew Creamer
Star Staff Writer
10-10-2002

TOOELE COUNTY, Utah

A valve problem last January at Utah's chemical weapons incinerator was not properly reported - a mistake that led to a worker's exposure to sarin nerve agent six months later, according to an Army investigation.

The problem, caused by valves stuck in the open position on the air-purge line for one of the
facility's two liquid-agent burners, was solved quickly and recorded in some logbooks. But, despite urgings from the Army, the contractor did not incorporate the valves' failing into later work on a purge line for the second burner.

This, along with the "false assumption" that the facility was decontaminated because it was being changed to handle different agent, led to the exposure, the investigation concluded.
Because he had no warning of the possibility agent would be in the system, the worker was
wearing a lower grade of protective gear than he should have been. He displayed minor symptoms after the exposure, and was cleared for work the next day.

The incident halted non-essential activities at the Tooele County plant and triggered investigations by the contractor, EG&G, the Army and the Department of Defense Inspector General. An executive summary of the Army's report was released Wednesday, along with a plan to improve safety at the plant.

More than a technical rendering of the incident, the summary suggests shortcomings in training and communication and details a breakdown in "lessons learned," the program that facilitates the sharing of information among the nation's chemical weapons incinerators.

The summary places blame on the facility's management rather than on the facility or incineration technology. "The problem with the valves was not a direct cause of the exposure," said Greg Mahall, spokesman for the Army's Program Manager for Chemical Demilitarization. "The simple fact that the valves failed contributed to the event.

"This exposure could have been avoided if a more cautious or conservative work plan approach had been executed," he said.

An incinerator critic said the report undermines the Army's praise of its internal
information-sharing program. "It is nothing short of astonishing that the Army has, for the past 10 years, represented to Congress, the public and the media that they have a 'robust' lessons-learned program," said Craig Williams, director of the Chemical Weapons Working Group, which opposes incineration.

"It appears, once again, that in spite of the rhetoric of 'safety first' that schedule and the perception that this technology is capable of doing the job is the Army's top priority," he said.

The narrative created by the investigation begins in January 2002, when GB agent was seen
dripping from a newly installed air-pressure regulator in the air-purge line. This line blows residual agent out of the pipes running from the storage tanks to the combustion chamber. A new set of valves was installed by workers who wore top-level protective equipment because the facility was burning agent at the time.

This work was entered in logs, but not in a set of technical drawings that are updated periodically to show where the presence of agent should be expected. Neither did EG&G personnel include it in a lessons-learned program. This, despite the Army's encouragement at the time "that measures should be taken to validate the integrity of the check valves and the block valve through which agent migrated."

Without this being done, work was done on the air pressure regulator for the second liquid-agent incinerator. By July 15, the facility was in the midst of a changeover period, during which equipment was cleaned and monitors and other equipment were being converted for the beginning of the VX campaign.

Two workers wearing industrial respirators, overalls and leather boots and gloves removed a
section of pipe from the air-purge line and set it on the floor. Agent alarms immediately sounded, and the worker who had handled the pipe took off his respirator and donned the military-issued gas mask attached to his belt. In doing so, he spread agent from his glove to his head and hair as they left the room.

This, according to the summary, was the beginning of a series of errors in emergency and medical response to the incident. First, neither water nor decontamination solution was brought to the scene. Medical personnel were absent. Then the wrong kind of portable monitoring equipment was brought in. It "became saturated with agent and defaulted to a reading of 0.0."

More problems manifested in the facility's medical clinic. The staff failed to administer an antidote and the exposed worker failed to report all of his symptoms. Doctors immediately observed that his pupils were pinpointed, but it wasn't until the next day that they learned of his disorientation, headaches, blurry vision, tightness in the chest and runny nose.

Why didn't the worker, who had been in the decontamination vestibule for almost four hours, report all the symptoms? He was "tired of being scrubbed," according to the EG&G report.

In addition to releasing the safety plan, the Army is preparing a corrective action plan to be sent to all of the incinerator sites, said Mahall, who noted that the lessons-learned program already is being revised. The deputy program manager, Delbert Bunch, "had already directed that steps be taken to develop a new lessons-learned program, emphasizing worker and facility safety, oriented to site-specific needs, implementing enhanced worker-concerns programs, and to create a database accessible to other interested parties," Mahall said.
"Any one of several persons in the contractor's organization could have raised a question that would have had the effect of precluding this incident," Mahall said. "The (Army) field office cannot be a substitute for contractor management, although a more aggressive oversight role before the start of work might have prevented the exposure," he said.

A spokesman for EG&G declined comment, saying corporate management had not yet reviewed the summary. However, the company's own investigation, leaked to the media recently, came to similar conclusions. "No one recognized the incident on January 16, 2002 as a near miss," it reads. "This overall inaction indicated the project safety culture needs improving."

One incinerator critic said the report is a case of the Army "passing the buck" to the contractor when it should be examining problems within the incinerator program.
"The Army is pointing the finger at someone else when they should be taking a hard look in themirror and asking why the same internal problems exist today that were identified almost a decade ago," said Jason Groenewold, director of Families Against Incinerator Risk in Utah.

A spokesman for the Anniston incinerator, Mike Abrams, spoke only generally about the effect the Army findings will have here. "We're making sure we have policies and procedures in place to preclude us from having an incident here," Abrams said.

The systems contractor for the Anniston incinerator is Westinghouse Anniston.

The Tooele plant, Mahall said, is not expected to begin burning VX until November or December.