Defense Environment Alert
April 8, 2003

DOD IG DOCUMENTS LACK OF 'SAFETY CULTURE' AT UTAH INCINERATOR

The Pentagon's inspector general (IG) in a new report finds the Army's chemical weapons incinerator in Utah lacked a documented process for reporting safety concerns, that communication between employees and supervisors was ineffective and employees were not comfortable raising concerns to their direct supervisor, and that more than half the employees believed management placed production above safety.

The main objective of the March 28 report, Army Response to Chemical Agent Incident at Tooele Chemical Agent Disposal Facility, was to determine if an Army investigation of a July 15, 2002, incident where a worker was exposed to nerve agent was sufficient. Additionally, the IG assessed the safety reporting process at the facility.

"Provided the Army accurately tracks and verifies the correction of identified deficiencies, the investigation will have met the intent and purpose of preventing accident recurrence," the IG says. But the report also notes that DOD policy and Army regulations did not provide specific guidance governing the investigation of the July 15 incident because a contract employee, and not Army personnel, was exposed. And the IG says a survey of 212 Tooele workers produced contradictory yet potentially disturbing results regarding safety communication. The report is available on InsideEPA. com. See page 2 for details.

Last fall, a high-level Army investigation found that failure to properly document design changes and false assumptions about where nerve agent was likely to be present contributed to the July 15 incident. The Army investigation also found the incident revealed several weaknesses in procedures used to respond to the agent exposure (Defense Environment Alert, Oct. 22, 2002, p 10). The Army investigation made 50 findings, including 12 direct causes, 20 indirect causes and 18 observations, and developed 97 recommendations for corrective actions directed at the systems contractor and multiple organizations within the Army, the IG says.

In the July 15 incident, two contractor maintenance workers entered the primary liquid incinerator room wearing minimum-level personal protective equipment to perform non-routine maintenance requiring the exchange of an air pressure regulator. Following the removal of a section of pipe containing the existing air pressure regulator, a portable GB agent monitor alarm sounded and both workers exited the room. As the workers were changing into more protective respirators, the worker who had handled the pipe transferred agent from his leather glove to his head, hair and respirator. The two workers then spent almost four hours undergoing repeated decontamination cycles before medical personnel declared them free of contamination. "This chemical event was the first reported significant exposure to a worker during the life of the [chemical demilitarization] program," the IG says.

The IG finds Tooele "did not have a healthy safety culture, defined as a set of attitudes and attributes reflected in workers, supervisors, and managers that safety is the fundamental priority and prerequisite for doing work." The IG reached this conclusion by interviewing the plant's contractor employees, attending a meeting of the safety committee and conducting an anonymous safety opinion survey of 212 employees with plant access from the day and evening shifts, the report says.

The survey indicated that approximately one-quarter of the respondents believed management either dismissed or did not adequately respond to their concerns, the IG says. "We conclude that due to a lack of a documented process, neither the contractor nor the Army could verify or disprove this belief."

The IG also "identified that communication between employees and supervisors was ineffective and employees were not comfortable raising concerns to their direct supervisor." But the survey also produced contradictory views on this communication. Specifically, 82 percent of respondents were comfortable raising a safety concern to their supervisor, 93 percent were aware of the safety reporting process, and 88 percent believed management encourages safety reporting. But, 24 percent said they would be more comfortable reporting concerns outside of the company, and 16 percent said they had been told to fix a problem and not report it. "A more disturbing result was that eight respondents indicated knowledge of an unreported worker exposure," the IG says.

The survey indicated that 52 percent of employees believed that management placed production above safety, and 12 percent knew of persons that reported safety concerns and were later terminated. The IG says the Army assistant secretary for installations and environment, who at the time had oversight authority, was also concerned about the perception that the contractor stressed production over safety, leading the official to change the plant's operations contract, which had included a million dollar bonus if the contractor completed destruction of GB agent prior to the opening of the 2002 Winter Olympic Games in Utah.

While generally satisfied with the Army's investigation of the incident, the IG report says there were two significant omissions in the Army report: "there was no stated completion date for a corrective action plan, and root causes did not address engineering failures." But the IG says implementation of the Army report's recommendations should address the engineering problem.