Hermiston Herald A-1, Oct. 11, 2002:

Safety procedures modified at depot

By Frank Lockwood
Staff writer

HERMISTON - Umatilla Chemical Agent Disposal Facility is subject to modified
safety procedures, in part due to the investigation of a worker's accidental
exposure to GB nerve agent at the Tooele Chemical Agent Disposal Facility
(TOCDF) in Utah.

The investigation summary answers some questions, raises others. For
example, why did the contractor apparently ignore known potential sources of
leaking GB? On July 15, 2002, Tooele workers were performing routine maintenance when
air monitors in the immediate area detected GB nerve agent. One worker
tested positive for exposure to chemical agent during the maintenance
procedure. The worker was decontaminated and placed under medical
observation. He was cleared to return to work the following day.

Immediately after the event, PMCD halted all operations at the facility
except those necessary to maintain safe and stable conditions, and the Army
launched an intensive investigation to determine the cause of the accident,
implement corrective measures and prevent any future occurrences.

The safety improvement program directs PMCD and its systems contractors to
maximize efforts to promote a universal safety culture among the plant
workers, improve communications and coordination among engineering, safety,
operations and maintenance personnel to improve the internal processes to
share lessons learned at the facility; and ensure all future operations
plans include the proper checks and balances to provide maximum worker
protection. A corrective action plan that responds to the recently completed
Army Board of Investigation Report is being separately prepared.

The goals of the safety improvement program are to assure worker safety,
protection of the environment and compliance with applicable laws and
regulations. Measures have been identified which will be incorporated not
only at the TOCDF, but at every future disposal site to ensure that this
type of event does not occur again.

"The improvements identified following the Tooele event are being adopted at
Umatilla," said Don Barclay, Army site project manager at the Umatilla
Chemical Agent Disposal Facility. "Safety remains our top priority."

Some of the safety issues identified at Tooele were reported by a Board of
Investigation. The board was established in July, 2002, by the assistant
secretary of the Army for Installations and Environment, and produced a
summary of events surrounding the Tooele accident. Parts of the sequence of
events revealed in the summary are as follows:

Liquid Incinerator 1

• Spring 2001: A pressure regulator was causing emissions problems. The
  problems occurred whenever one collection tank was drained empty, and the
  system was therefore switched over to draw agent from another tank. When
  those switch-overs happened, monoxide levels exceeded allowed limits. An
  engineering change was subsequently made to modify the pressure regulator,
  in order to purge lines of agent at lower pressures, and thus eliminate
  monoxide "spiking" in the emissions. The regulator was modified and
  installed.
  
• January 2002: High levels of agent GB were detected in an area where the
  agent was not supposed to be. using remote cameras, control room operators
  identified the source of agent leakage: GB was observed dripping from the
  newly installed, modified air pressure regulator.
  · Through engineering observations and analysis, it was determined that two
  check valves and a "block valve" in the backflow isolation devices were
  "frozen" in the open position and could not be repaired.
  ·
• Feb. 5, 2002: The PMCD Field Office sent a formal advisory letter to the
  System Contractor's Plant Manager, cautioning that the modification of the
  LIC 1 Primary air pressure regulator had been approved and was being planned
  for LIC 2 Primary and that measures should be taken to validate the
  integrity of the check valves and block valve. However, the System
  contractor did not respond to the letter, nor was it placed in the System
  Contractor's action tracking system or correspondence control tracking
  system.
  ·
• Neither the System Contractor nor PMCD Field Office personnel provided
  notification of the incident to PMCD's centralized lessons learned database.
  Liquid Incinerator 2
  ·
• Spring 2002: Work began to modify the pressure regulator for LIC2 Primary.
  No steps were included to verify the integrity of the two check valves and
  block valve, as previously suggested by the PMCD Field Office. The Work
  Order prepared by the LIC System Engineer did not mention the prior incident
  involving migration of agent into the LIC 1 Primary purge air regulator and
  the potential for a similar situation on the LIC 2 Primary.
  ·
• July 15, 2002: Two maintenance workers entered the LIC 2 Primary Room
  wearing full face industrial respirators approved by the National Institute
  of Occupational Safety and Health, overalls, and leather boots and gloves,
  do install the modified air pressure regulator. They were loosening
  couplings with a wrench and by hand for a three-foot section of purge air
  line containing the air pressure regulator when a portable GB Monitor alarm
  went off. They removed their industrial respirators and donned their
  government respirators. During the change of masks, some of the
  contamination from the leather glove of the worker who had handled the pipe
  was transferred to his head, hair, and/or respirator. The two workers were
  moved to a room called LIC 2 Secondary Room for assessment.
  
• During their assessment in the LIC 2 Secondary Room, problems arose
  regarding the monitor readings. About an hour after the initial alarm, the
  two maintenance workers were released from the LIC 2 Secondary Room, based
  on the inaccurate perception that they had cleared at least two monitoring
  cycles. They unmasked and were transported to the medical clinic without
  having undergone decontamination or preliminary medical evaluation. When
  they arrived in the Clinic's Decontamination Vestibule, however, alarms
  indicated that one or both of them were contaminated.
  ·
• The two maintenance workers spent about four hours in the Decontamination
  Vestibule undergoing repeated decontamination cycles before they were
  declared free of contamination and brought into the Clinic Treatment Area
  for evaluation. Atropine was not administered, but a doctor observed one of
  the workers to have experienced miosis (reduction of the eye pupil). Later
  it was learned he also experienced disorientation, headaches, blurry vision,
  tightness in the chest and a runny nose, but he did not report these
  symptoms to the medical staff while he was in the Clinic Decontamination and
  Monitoring Vestibules and under observation. Later blood analyses indicated
  a 25 percent depression of red blood cell cholinesterase from the worker's
  baseline. The miosis and red blood cell cholinesterase depression are
  indicative of exposure to GB.

Army and PMCD personnel directed the Hermiston Herald to Greg Mahall in
Maryland as the person most familiar with the Tooele situation. We called
and faxed messages to Mahall in the early afternoon but he was not able to
respond before we went to press. Some of the questions we presented were:

• Were the check-valves mentioned as "frozen" deliberately altered or
  disabled?
  
• When was it first known that the check-valves were not functional?
  
• Why didn't the system contractor respond to the PMCD's Feb. 5 letter which
  advised them to validate the operation of the check valves?
  
• Why wasn't the PMCD letter concerning the check-valves placed in the
  system contractor's tracking system?
  
• Why weren't steps taken to verify the integrity of the two check valves
  and the block valve?

Mahall was not available, and his boss, Marilyn Daughdrill, said she did not
know the answers to our questions. Program Manager for Chemical
Demilitarization staff was checking to see who might have that information,
she said.

A copy of the safety improvement program and an executive summary of the
Army Board of Investigation Report can be obtained by contacting or visiting
the Umatilla Chemical Disposal Outreach Office at (541) 564-9339, 190 E.
Main, Hermiston, Ore., 97838.

n Frank Lockwood may be reached at 567-6457 or by e-mail at
flockwood@hermistonherald.com.