'ROUTINE' TO BLAME FOR DEPOT ERROR
Published: September 21, 2004
By Karen Hutchinson-Talaski
Staff writer
HERMISTON — The workers who inadvertently entered the Toxic Cubicle at the chemical agent disposal facility appeared to do so because they had "routinely used the route" before agent operations began.
That's what Doug Hamrick, project manager for the Washington Demilitarization Company told the Citizen's Advisory Commission at their meeting Thursday evening.
Apparently, Hamrick said, when practice entries were done prior to start-up of agent operations, the practice had been to go through the Toxic Cubicle door.
"We conditioned them to enter that door," Hamrick said. "Although we covered the door numbers extensively, they still went through the wrong door."
The WDC says it have taken several corrective actions to ensure the error does not happen again.
According to Hamrick, training has been increased, doors have larger signs indicating the room name and number, and the company is now treating Level C (rubber suit and gas mask) entries just as if they were DPE (moon suit) entries.
"DPE entries are always on camera," Hamrick said. "We will treat Level C entries with the same rigor and discipline as DPE entries."
Multiple cameras are set up in each room of the chemical disposal site. A control room operator is in charge of each entry. He or she is in control of the cameras. If radio contact is lost for any reason, even if it is one radio, the practice is to abort the entry.
Hamrick said a 45-minute pre-job brief was given to the two workers before they entered the waste disposal room. Their job was to gather the DPE suits for disposal.
One of the workers asked to go over the alternative exit and was shown a map to determine the correct route.
"They were supposed to go through the left door," Hamrick said. "They went to the right. In this case, it was low-level exposure."
The workers went through the Toxic Cubicle twice before the control room operator realized what had happened. When the operator noticed the workers coming out of the Toxic Cubicle room, the operation was halted.
The room where the workers needed to be was on the other side of the Toxic Cubicle.
The workers were tested twice for agent contamination. Blood was drawn after the incident and then again 12 hours later, per protocol. No contamination was found in their blood and only low levels of agent were found in the room.
"That was just luck," Hamrick said.